General practitioners’ views on radiology reports of plain radiography for back pain

Scand J Prim Health Care 2003;21:15-20. ISSN 0218-3432 Objective -?To analyse the influence of rates of general practitioner visits on rates of hospitalisations. Design?-?Ecological cross-sectional study of factors influencing hospitalisation rates. Aggregated data on primary care centre area level. Setting?-?The county of ÖstergÖtland, Sweden, with 3 hospital districts and 41 primary health care centres, and the hospital district of JÖnkÖping in the county of JÖnkÖping, Sweden, with 11 primary health care centres. Outcome measure?-?Hospitalisation rates. Results?-?Age and rates of outpatient hospital visits were the most important factors explaining the variation in rates of hospitalisations between the primary health care centre areas. Hospital districts, socioeconomic factors and rates of GP visits also influenced the rates of hospitalisations. Conclusion?-?When evaluating the influence of primary health care on the rates of hospitalisations, both socioeconomic factors and health care structure must be taken into consideration. Doing this, the rates of GP visits correlated negatively with the rates of hospitalisations.     

If a joint is hot it’s not the time: health professionals’ views on developing an intervention to promote physical activity in rheumatoid arthritis

Purpose: The study aimed to explore the views of health professionals on (i) physical activity in people who have rheumatoid arthritis (RA) and (ii) the design of an intervention to promote physical activity in this population.

Method: We used a qualitative methodology and conducted 14 interviews (rheumatologists n?=?7, physiotherapist n?=?4, clinical nurse specialists n?=?3). Interviews were transcribed verbatim and analyzed using thematic analysis.

Results: Three key themes were generated: “Personal opinions”, “Supporting physical activity” and “An ideal world”. Although health professionals viewed physical activity as important, recommending it to people who have RA was largely based on persons’ disease status rather than empirical evidence. Resources were highlight as a key challenge to interventions in clinical practice. Supporting physical activity through provision of information, goal setting and monitoring was also discussed.

Conclusion: Health professionals believe physical activity is important for people who have RA, although there is uncertainty regarding physical activity recommendations for this population. Thus, there is scope to increase health professionals’ knowledge of recent evidence. Views varied on how an intervention to promote physical activity should be delivered, but consideration of barriers to delivery in clinical practice is important.

• Implications for Rehabilitation

• Physical activity is an important aspect of disease management for people who have rheumatoid arthritis.

• Health professionals need to acknowledge the “mixed messages” received by people who have RA about being physically active thus further education for health professionals is suggested to standardize physical activity advice in clinical practice.

• Health professionals may benefit from education about behavior change theory and techniques.

• When designing future physical activity interventions consideration of the practical challenges of implementing research in a clinical setting is necessary.

     

General practitioners’ experiences with provision of healthcare to patients with self-reported multiple chemical sensitivity

Objective

To describe general practitioners’ (GPs’) evaluation of and management strategies in relation to patients who seek medical advice because of multiple chemical sensitivity (MCS).

Design

A nationwide cross-sectional postal questionnaire survey. The survey included a sample of 1000 Danish GPs randomly drawn from the membership list of GPs in the Danish Medical Association.

Setting

Denmark.

Results

Completed questionnaires were obtained from 691 GPs (69%). Within the last 12 months 62.4% (n = 431) of the GPs had been consulted by at least one patient with MCS. Of these, 55.2% of the GPs evaluated the patients’ complaints as chronic and 46.2% stated that they were rarely able to meet the patients’ expectations for healthcare. The majority, 73.5%, had referred patients to other medical specialties. The cause of MCS was perceived as multi-factorial by 64.3% of the GPs, as somatic/biologic by 27.6%, and as psychological by 7.2%. Partial or complete avoidance of chemical exposures was recommended by 86.3%. Clinical guidelines, diagnostic tools, or more insight in the pathophysiology were requested by 84.5% of the GPs.

Conclusion

Despite the lack of formal diagnostic labelling the patient with MCS is well known by GPs. The majority of the GPs believed that MCS primarily has a multi-factorial explanation. However, perceptions of the course of the condition and management strategies differed, and many GPs found it difficult to meet the patients’ expectations for healthcare. The majority of the GPs requested more knowledge and clinical guidelines for the management of this group of patients.     

Problems and challenges in relation to the treatment of patients with multimorbidity: General practitioners’ views and attitudes

Objective. To explore views and attitudes among general practitioners (GPs) and researchers in the field of general practice towards problems and challenges related to treatment of patients with multimorbidity. Setting. A workshop entitled Patients with multimorbidity in general practice held during the Nordic Congress of General Practice in Tampere, Finland, 2013. Subjects. A total of 180 GPs and researchers. Design. Data for this summary report originate from audio-recorded, transcribed verbatim plenary discussions as well as 76 short questionnaires answered by attendees during the workshop. The data were analysed using framework analysis. Results. (i) Complex care pathways and clinical guidelines developed for single diseases were identified as very challenging when handling patients with multimorbidity; (ii) insufficient cooperation between the professionals involved in the care of multimorbid patients underlined the GPs’ impression of a fragmented health care system; (iii) GPs found it challenging to establish a good dialogue and prioritize problems with patients within the timeframe of a normal consultation; (iv) the future role of the GP was discussed in relation to diminishing health inequality, and current payment systems were criticized for not matching the treatment patterns of patients with multimorbidity. Conclusion. The participants supported the development of a future research strategy to improve the treatment of patients with multimorbidity. Four main areas were identified, which need to be investigated further to improve care for this steadily growing patient group.     

Self-management support at the end of life: Patients’, carers’ and professionals’ perspectives on managing medicines

BackgroundPain is a frequently reported symptom by patients approaching the end of life and well-established that patients and carers hold fears relating to opioids, and experience side effects related to their use. The management of medicines is intrinsic to achieving effective pain relief. The concept of self-management support whilst well characterised in the context of chronic illness has not been elaborated with respect to end of life care.AimTo identify patient, carer and professional views on the concept of self-management support at end of life, specifically in relation to analgesia and related medicines (for side-effect management) in order to describe, characterise and explain self-management support in this context.Methodology & methodsQualitative design, data collection methods involved focus groups and interviews. Topics included the meaning of self-management support in this context, roles and behaviours adopted to manage pain-related medicines, and factors that influence these. A largely deductive approach was used, involving verification and validation of key frameworks from the literature, but with capacity for new findings to emerge.SettingParticipants were drawn from two different localities in England, one North, the other South. Interviews with patients and carers took place in their own homes and focus groups with healthcare professionals were held at local hospices.Participants38 individuals participated. 15 patients, in the last year of life, and 4 carers under the care of community-based specialist palliative care services and 19 specialist palliative care health professionals (predominantly community palliative care nurses).FindingsThe concept of self-management support had salience for patients, carers and specialist nurses alongside some unique features, specific to the end of life context. Specifically self-management was identified as an ever-changing process enacted along a continuum of behaviours fluctuating from full to no engagement. Disease progression, frequent changes in symptoms and side-effects, led to a complex web of roles and behaviours, varying day by day, if not hour by hour. Data confirmed previously proposed professional roles were enacted to support self-management. Furthermore, as patients, carers and clinical nurse specialists worked together to achieve effective pain management, they enacted and inter-acted in the roles of advocate, educator, facilitator, problem solver, communicator, goal setter, monitor and reporter.ConclusionsThe study has demonstrated what self-management support at end of life entails and how it is enacted in practice.     

Variation in general practitioners’ information-seeking behaviour – a cross-sectional study on the influence of gender,age and practice form

Objective: To assess general practitioners’ (GPs’) information-seeking behaviour and perceived importance of sources of scientific medical information and to investigate associations with GP characteristics.

Design: A national cross-sectional survey was distributed electronically in December 2013.

Setting: Danish general practice.

Subjects: A population of 3440 GPs (corresponding to approximately 96% of all Danish GPs).

Main outcome measures: GPs’ use and perceived importance of information sources. Multilevel mixed-effects logit models were used to investigate associations with GP characteristics after adjusting for relevant covariates.

Results: A total of 1580 GPs (46.4%) responded to the questionnaire. GPs’ information-seeking behaviour is associated with gender, age and practice form. Single-handed GPs use their colleagues as an information source significantly less than GPs working in partnership practices and they do not use other sources more frequently. Compared with their younger colleagues, GPs aged above 44 years are less likely to seek information from colleagues, guidelines and websites, but more likely to seek information from medical journals. Male and female GPs seek information equally frequently. However, whereas male GPs are more likely than female GPs to find that pharmaceutical sales representative and non-refundable CME meetings are important, they are less likely to find that colleagues, refundable CME meetings, guidelines and websites are important.

Conclusion: Results from this study indicate that GP characteristics should be taken into consideration when disseminating scientific medical information, to ensure that patients receive medically updated, high-quality care.

• KEY POINTS

• Research indicates that information-seeking behaviour is associated with GP characteristics. Further insights could provide opportunities for targeting information dissemination strategies.

• Single-handed GPs seek information from colleagues less frequently than GPs in partnerships and do not use other sources more frequently.

• GPs aged above 44 years do not seek information as frequently as their younger colleagues and prefer other information sources.

• Male and female GPs seek information equally frequently, but do not consider information sources equally important in keeping medically updated.

     

Procedure for rehabilitation of the knee following synovectomy in patients with rheumatoid arthritis at the Poznań Rheumatological Center in Srema

At the Poznań Rheumatology Center in Srema synovectomy of the knee joint is one of the treatment methods applied in cases where "rheumatoid granules" occur in the knee, or in recurrent exudative infections. One of the essential elements of therapy is to begin post-operative rehabilitation with active exercises as soon as 48 hours after surgery. This method is used to eliminate adhesions in the operating field and achieve a full range of movement in the joint without the need to apply painful and injurious redressing of the joint. The procedure used with the patient after surgery and the choice of kinesitherapeutic methods is the result of many years of experience. Post-operative procedures are concluded within 2-3 weeks when the range of movement achieved in the joint is greater than or equal to pre-operative.     

Barriers to adequate pain and symptom relief at the end of life: A qualitative study capturing nurses’ perspectives

BackgroundSymptom management remains a critical challenge at the end of life. Barriers to symptom relief predominantly focus on perspectives of physicians, patients or care systems but rarely acknowledge the views of nurses.AimExamine nurses’ perceptions of barriers to adequate end-of-life symptom relief.MethodsSemi-structured interviews with 25 nurses across different settings who routinely prescribed and/or administered symptom relief to patients near the end of life in Queensland and New South Wales, Australia. Data were analysed using a six-stage hybrid thematic analysis technique.FindingsNurses identified five barriers to adequate symptom management. Firstly, fears concerning symptom relief such as hastening death, causing addiction, loss of consciousness, and legal/professional repercussions affected clinical practice. Secondly, lack of knowledge, experience and training hindered symptom management. Nurses discussed knowledge gaps regarding medication and palliative care, symptom assessments, recognition of dying and relevant laws. Thirdly, personal, cultural and religious beliefs influenced staff's willingness to offer pain relief, and patients’ and families’ willingness to accept it. Lack of communication between medical teams, patients and families further challenged symptom management. Lastly, institutional barriers played a considerable role as time constraints, insufficient staff support and difficulties accessing resources prevented end-of-life symptom management.DiscussionThe identified barriers highlight a substantial need for targeted interventions. Setting-specific challenges such as limited access to medication, staff and palliative care services must be addressed.ConclusionsTo provide better end-of-life care, services should acknowledge nurses’ unique insights. Particular attention should be on supporting nurses in aged care facilities, community settings and remote areas.     

Levofloxacin: update and perspectives on one of the original ‘respiratory quinolones’

The fluoroquinolone class of antimicrobials has enjoyed enormous clinical and marketing success over the past 20 years. These drugs have proven to be extremely useful in a broad range of clinical indications including both common community-acquired as well as nosocomial bacterial infections. Levofloxacin (Levaquin^®, Tavanic?), like ciprofloxacin (Cipro^®), has established an enviable record of safe and efficacious use, and in many ways has become the agent against which all of the newer fluoroquinolones are judged. New clinical indications in complicated skin and skin structure infections, nosocomial pneumonia and chronic bacterial prostatitis continue to expand the important role of this already versatile drug. In addition, the use of ‘short-course, high-dose’ therapies are being studied in indications, such as community-acquired pneumonia, in an effort to optimize the efficacy and convenience of the drug while minimizing the future development of resistance. As the use of levofloxacin continues to expand, future challenges will include the threat of increasing antimicrobial resistance and the availability of newer alternative agents, both newer fluoroquinolones as well as agents of other antibiotic classes.     

Nurses’ perspectives regarding the disclosure of errors to patients: A qualitative study

BackgroundThere is often a mismatch between patients’ desire to be informed about errors and clinical reality. In closing the “disclosure gap” an understanding of the views of all members of the healthcare team regarding errors and their disclosure to patients is needed. However, international research on nurses’ views regarding this issue is currently limited.ObjectivesExplore nurses’ attitudes and experiences concerning disclosing errors to patients and perceived barriers to disclosure.DesignInductive, exploratory study employing semi-structured interviews with participants, followed by conventional content analysis in which investigators read and discussed transcribed data to identify important themes.SettingsNursing departments from hospitals in two German-speaking cantons in Switzerland.ParticipantsPurposive sample of 18 nurses from a range of fields, positions in organisational hierarchy, work experience, hospitals, and religious perspectives.MethodsData were collected via individual, face-to-face interviews using a researcher–developed semi-structured interview guide. Interviews were transcribed in German and analysed using the qualitative data analysis software package Atlas-Ti (Berlin) and conventional content analysis. The most illustrative quotes were translated into English.ResultsNurses generally thought that patients should be informed about every error, but only a very few nurses actually reported disclosing errors in practice. Indeed, many nurses reported that most errors are not disclosed to the patient. Nurses identified a number of barriers to error disclosure that have already been reported in the literature among all clinicians, such as legal consequences and the fear of losing patients’ trust. However, nurses in this study more frequently reported personal characteristics and a lack of guidance from the organisation as barriers to disclosure. Both issues suggest the need for a systematic institutional approach to error disclosure in which the decision to inform the patient stems from within the organisation and is not shouldered by individual nurses alone.ConclusionsOur study suggests that hospitals need to do more to support and train nurses in relation to error disclosure. Such measures as hospitals establishing a disclosure support system, providing background disclosure education, ensuring that disclosure coaching is available at all times, and providing emotional support for all parties involved, would likely go a long way to address the barriers identified by nurses.     

A survey of Canadian cancer patients’ perspectives on the characteristics and treatment of breakthrough pain

Objective

Breakthrough pain is defined as a transient exacerbation of pain that occurs spontaneously or in response to a trigger despite stable and controlled background pain. The purpose of this study was to explore Canadian patients’ awareness of and experience with breakthrough pain in cancer (BTPc).

Methods

Four Canadian cancer centers participated in a non-interventional survey recruiting cancer patients who experienced breakthrough pain. These patients were asked about their pain, its impact on functioning, current management and interest in new treatments of BTPc.

Results

Ninety-four Canadian cancer patients participated in this study, with 96 % stating that cancer pain impacted their daily living with over half unable to go to work or shopping. Fifty percent of patients said that an episode of BTPc lasted greater than 60 minutes, with the pain score being on average 7.8/10, impacting normal work (7.2/10) and general activity (7.1/10). Only 35 % of patients were very satisfied with the speed of relief of their medications. Those who did not take their breakthrough pain medication for every episode stated that was because the pain was not always severe (37 %), or they were afraid of becoming tolerant (23 %) or addicted (12 %). Patients stated that the most important features of a new treatment for BTPc were the ability to relieve pain completely (47 %), and quickly (43 %). Patients expressed willingness to try transmucosal products (80 %) or nasal products (59 %).

Conclusion

Breakthrough cancer pain in Canadian cancer patients greatly impacts their daily lives. There is room for improvement in the management of BTPc, and the majority of patients would be willing to try new treatments.     

Patients’ perspectives on the use of the Montgomery-Asberg depression rating scale self-assessment version in primary care

Objective: The aim of the current study was to better understand how patients with depression perceive the use of MADRS-S in primary care consultations with GPs.

Design: Qualitative study. Focus group discussion and analysis through Systematic Text Condensation.

Setting: Primary Health Care, Region Västra Götaland, Sweden.

Subjects: Nine patients with mild/moderate depression who participated in a RCT evaluating the effects of regular use of the Montgomery-Åsberg Depression Self-assessment scale (MADRS-S) during the GP consultations.

Main Outcome measure: Patients’ experiences and perceptions of the use of MADRS-S in primary care.

Results: Three categories emerged from the analysis: (I) confirmation; MADRS-S shows that I have depression and how serious it is, (II) centeredness; the most important thing is for the GP to listen to and take me seriously and (III) clarification; MADRS-S helps me understand why I need treatment for depression.

Conclusion: Use of MADRS-S was perceived as a confirmation for the patients that they had depression and how serious it was. MADRS-S showed the patients something black on white that describes and confirms the diagnosis. The informants emphasized the importance of patient-centeredness; of being listened to and to be taken seriously during the consultation. Use of self-assessment scales such as MADRS-S could find its place, but needs to adjust to the multifaceted environment that primary care provides.

• Key Points

• Patients with depression in primary care perceive that the use of a self-assessment scale in the consultation purposefully can contribute in several ways. The scale contributes to

• Confirmation: MADRS-S shows that I have depression and how serious it is.

• Centeredness: The most important thing is for the GP to listen to and take me seriously.

• Clarification: MADRS-S helps me understand why I need treatment for depression.

     

No easy way to exterminate ‘superbugs’ at the dawn of the third millennium

Truvada^® is the coformulation of tenofovir disoproxil fumarate (TDF; 300 mg) and emtricitabine (FTC; 200 mg) in a single tablet, providing the nucleotide backbone for once-daily dosing, as a component of highly active antiretroviral therapy (HAART). TDF (the bioavailable prodrug of tenofovir) is hydrolyzed to tenofovir intracellularly and phosphorylated to the active metabolite, tenofovir diphosphate. Tenofovir is a nucleotide analog of deoxyadenosine monophosphate, with activity against HIV-1, -2 and hepatitis B virus. FTC, the fluorinated derivative of lamivudine, is an analog of deoxycitidine, active against HIV-1, -2 and hepatitis B virus. Their long half-lives in plasma and in peripheral blood mononuclear cells allow once-daily dosing. Both are eliminated renally. Resistance mutation K65R is selected for by tenofovir and confers a two- to fourfold reduced susceptibility to this drug. The incidence of K65R is low (3%) and has not been observed in clinical trials with the concomitant use of tenofovir and FTC. FTC selects for M184V mutation less frequently than lamivudine. Tenofovir drug interactions include increased exposure to didanosine and inferior immmune recovery that preclude their concomitant use. Boosted protease inhibitors increase exposure to tenofovir without dose adjustment required. FTC has no significant drug interactions. They are not metabolized by cytochrome P450, which confers little potential for interactions with drugs metabolized by these enzymes. As tenofovir and FTC are renally eliminated, drugs eliminated by tubular secretion must be avoided. Both antiretrovirals, as individual agents and in coadministration have evidenced antiviral potency in clinical trials. Pivotal study 934 evidenced superior efficacy of the combination TDF/FTC/efavirenz (EFV) versus zidovudine/FTC/EFV. The toxicity profile of tenofovir and FTC has been extensively studied. Lipid profile is more favorable with tenofovir than thymidine analog. Tenofovir requires surveillance of glomerular filtration rate and dosing interval adjustment when creatinine clearance is less than 50 ml/min and avoidance less than 30 ml/min. Fat loss is less likely with tenofovir than with thymidine analog. Clinical trials have assessed the performance of the coformulation of TDF and FTC.