General practitioners’ views on leadership roles and challenges in primary health care: a qualitative study

Objective: To explore general practitioners’ (GPs) views on leadership roles and leadership challenges in general practice and primary health care.

Design: We conducted focus groups (FGs) with 17 GPs.

Setting: Norwegian primary health care.

Subjects: 17 GPs who attended a 5 d course on leadership in primary health care.

Results: Our study suggests that the GPs experience a need for more preparation and formal training for the leadership role, and that they experienced tensions between the clinical and leadership role. GPs recognized the need to take on leadership roles in primary care, but their lack of leadership training and credentials, and the way in which their practices were organized and financed were barriers towards their involvement.

Conclusions: GPs experience tensions between the clinical and leadership role and note a lack of leadership training and awareness. There is a need for a more structured educational and career path for GPs, in which doctors are offered training and preparation in advance.

• KEY POINTS

• Little is known about doctors’ experiences and views about leadership in general practice and primary health care. Our study suggests that:

• There is a lack of preparation and formal training for the leadership role.

• GPs experience tensions between the clinical and leadership role.

• GPs recognize leadership challenges at a system level and that doctors should take on leadership roles in primary health care.

     

Esophageal Doppler-guided fluid management decreases blood lactate levels in multiple-trauma patients: a randomized controlled trial

Introduction  

Esophageal Doppler was confirmed as a useful non-invasive tool for management of fluid replacement in elective surgery. The aim of this study was to assess the effect of early optimization of intravascular volume using esophageal Doppler on blood lactate levels and organ dysfunction development in comparison with standard hemodynamic management in multiple-trauma patients.     

Effect of prone position on hepato-splanchnic hemodynamics in acute lung injury

OBJECTIVE: To evaluate the effects of prone position on hepato-splanchnic hemodynamics, metabolism and gut mucosal energy balance. DESIGN: Prospective clinical study. SETTING: Medical intensive care unit in a university hospital. PATIENTS: Eleven hemodynamically stable patients with acute lung injury (ALI) requiring mechanical ventilation. INTERVENTION: Patients were studied in the supine position, after 90 min in the prone position and after 90 min of supine repositioning. MEASUREMENTS AND RESULTS: In addition to global hemodynamics we measured intra-abdominal pressure (IAP, bladder), hepato-splanchnic blood flow (HSBF, steady state indocyanine green technique using a hepatic vein catheter) and gastric mucosal-arterial PCO(2) gap (PCO(2) gap, automated air tonometry). Systemic hemodynamics did not change during the whole study. Prone positioning did not significantly affect IAP. HSBF as well as splanchnic oxygen consumption remained unaltered, too. Similarly, neither liver lactate uptake nor indocyanine green extraction were influenced by positional changes. Finally, stable regional hemodynamics were accompanied by an unchanged PCO(2) gap. CONCLUSION: We conclude that if IAP and systemic hemodynamics remain unaffected, the prone position in ALI patients compromises neither hepato-splanchnic perfusion nor gastric mucosal energy balance.     

Ethanol inhibition of porcine bioprosthetic heart valve cusp calcification is enhanced by reduction with sodium borohydride

BACKGROUND AND AIM OF THE STUDY: Previous studies have shown that ethanol pretreatment of glutaraldehyde (GA)-fixed porcine aortic valve cusps (GPAV) significantly reduces bioprosthetic leaflet calcification. The anti-calcification mechanism is due to extraction of cholesterol and phospholipids, and a permanent alteration in collagen structure. It was noted in experimental implants that ethanol-pretreated GPAV occasionally show low levels of calcification. The study aim was to investigate whether this was due to unreacted aldehyde residues and other reducible compounds resulting from GA cross-linking. METHODS: GPAV were cross-linked in GA (0.6%) and stored at pH 7.4 in 0.2% GA. Cusps were pretreated with ethanol (80%, pH 7.4) for 24 h. Experimental groups included ethanol-pretreated cusps and GA-fixed controls that were pretreated with either sodium borohydride or sodium cyanoborohydride. Differential scanning calorimetry was used to measure shrink temperature as a measure of cross-linking. Subdermal implants of valve cusp tissue were carried out in 21-day-old Sprague-Dawley male rats. Implants were retrieved at 21 days and samples assessed for the extent of calcification using chemical analyses for Ca, and microscopy studies. RESULTS: Ethanol pretreatment significantly inhibited calcification compared with controls (13.3 +/- 5.6 versus 119.2 +/- 6.6 micrograms Ca/mg tissue; p < 0.001). However, sodium borohydride reduction under optimized conditions combined with ethanol pretreatment optimally reduced calcification (1.16 +/- 0.1 microgram Ca/mg; p < 0.05), whereas levels after sodium cyanoborohydride treatment (23.6 +/- 10.4 micrograms Ca/mg) were not significantly different to those after ethanol alone. Neither reducing agent was effective in inhibiting calcification without ethanol pretreatment. Furthermore, the reducing agents had no significant effect on shrink temperature. CONCLUSION: Inhibition of GPAV calcification with ethanol pretreatment can be enhanced through the optimized use of reducing agents. This indicates that reducible aldehyde-related moieties are likely responsible for breakthrough calcification, even after ethanol pretreatment.     

Effect of chronic vagal nerve stimulation on interictal epileptiform discharges

We evaluated the effect of vagus nerve stimulation (VNS) on interictal epileptiform discharges (IEDs) in 32 epileptic patients (18 females; 14 males) with an average age of 42.2 ± 11.4 years, all of whom had been suffering from epilepsy for an average of 29.2 ± 14.5 years. All of the patients had received VNS for 5 years. The first EEG was performed prior to the initiation of stimulation; the second EEG was performed at the 5-year follow-up visit. The duration of each EEG was 30 min. We compared these two EEGs in terms of the number of IEDs present in each patient and correlated them to other variables.The average total number of IEDs during EEG and the total number of seconds in which IEDs were present decreased significantly after 5 years of stimulation from 97.3 ± 106.9 resp. 80.6 ± 86.1 to 49.4 ± 94.0 resp. 37.8 ± 65.0. Although there was no positive correlation between the reduction of IEDs and the percent of seizure reduction, we found a greater decrease of IEDs in patients who responded to VNS in comparison to those who did not. The decrease of IEDs was more pronounced in patients suffering from temporal lobe epilepsy than in patients suffering from extratemporal epilepsy. No other significant correlations were found.VNS reduced IEDs in patients chronically simulated for epilepsy. The reduction of IEDs was greater in patients who responded to VNS and in patients suffering from temporal lobe epilepsy.     

Impaired metabolism in donor kidney grafts after steroid pretreatment

We recently showed in a randomized control trial that steroid pretreatment of the deceased organ donor suppressed inflammation in the transplant organ but did not reduce the rate or duration of delayed graft function (DGF). This study sought to elucidate such of those factors that caused DGF in the steroid‐treated subjects. Genome‐wide gene expression profiles were used from 20 steroid‐pretreated donor‐organs and were analyzed on the level of regulatory protein–protein interaction networks. Significance analysis of microarrays (SAM) yielded 63 significantly down‐regulated sequences associated with DGF that could be functionally categorized according to Protein ANalysis THrough Evolutionary Relationships ontologies into two main biologic processes: transport (P < 0.001) and metabolism (P < 0.001). The identified genes suggest hypoxia as the cause of DGF, which cannot be counterbalanced by steroid treatment. Our data showed that molecular pathways affected by ischemia such as transport and metabolism are associated with DGF. Potential interventional targeted therapy based on these findings includes peroxisome proliferator‐activated receptor agonists or caspase inhibitors.