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PubMed2000

Urban public attitudes to the treatment of psychological problems and depression in general practice.

A previous national study of public attitudes to depression indicated that only 17% spontaneously mentioned their general practitioner as someone who could help with depression, in contrast to 79% of respondents being willing to consult their G.P. in a similar U.K. survey. The present study undertook to examine the public perception of an urban sample to the treatment of depression in general practice and the factors associated with expressed unwillingness to consult. A random sample from the electoral register was drawn and 54 (89%) of 61 subjects selected were interviewed. While 85% of respondents were satisfied with their general practice care, only 24% to 52%, depending on the context and wording of the question, said that they would seek help from their general practitioner for depression. Factors associated with an expressed reluctance to consult were being male, dissatisfied with general practitioner care and believing that general practitioners were not qualified to treat depression.

Adolescent↗
PubMed1996

Audit of the care of patients with epilepsy in general practice.

BACKGROUND: Previous studies have shown that there is great potential for improving the management of patients with epilepsy. AIM: To identify all patients with epilepsy, to evaluate and audit their care in relation to an annual review, to document seizure frequency and appropriateness of daily therapy to aid compliance and to propose strategies to improve these and other aspects of epileptic care. METHOD: An audit of the care of patients with epilepsy was undertaken in two King's Lynn practices with a combined population of 22,500. Principles for the management of epilepsy were established. From these principles, the following standards were agreed: 75% of patients on treatment for epilepsy should be seen every year, 75% of patients should have their seizure frequency documented, and 75% of patients should take their anti-epileptic drugs no more than twice daily. As a result of the first audit cycle, changes were made in the documentation and advice regarding treatment relating to these standards. RESULTS: The first audit cycle showed that 83% of patients had been seen at least once in the previous year, that documentation of seizure frequency existed for 51% of patients in the past year, and that 63% of patients were taking their treatment no more than twice daily. The evaluation was repeated 22 months later and an overall improvement was demonstrated in the first two results: 95% of patients had been seen in the past year, 93% had had their seizure frequency documented; however, only 66% of patients were taking their treatment twice daily or less. CONCLUSION: Call and recall, and documentation of seizure frequency were improved by this clinical audit. However, alterations in daily therapy appeared difficult for a variety of reasons; for example, therapy might have been initiated by a hospital specialist, and patients in a stable condition might have been apprehensive about changes. In order to improve the care of patients with epilepsy, a primary care team approach is desirable within a structure of good specialist services.

Anticonvulsants↗
PubMed2000

Improving management of bereavement in general practice based on a survey of recently bereaved subjects in a single general practice.

BACKGROUND: Previous studies of bereavement in primary care have tended to concentrate on the attitudes of general practitioners (GPs) to bereavement support and little has been documented on the views of patients. AIM: To establish the role, content, and value of a protocol designed to help the newly bereaved by examining the experiences and expectations of a group of bereaved patients within a single general practice, with a view to developing patient care within this area. METHOD: A qualitative approach was adopted using a semi-structured questionnaire, data collection, and analysis consistent with the principles of grounded theory. Patients were approached by letter and those who agreed to take part in the study were interviewed at home. RESULTS: Many of those interviewed expected some form of contact from their GP after bereavement, although the nature of the contact they would have liked varied. The majority would have appreciated a letter of sympathy and none would have objected to it. Over half expressed some form of dissatisfaction either with their GP or with the hospital. Quality of information giving and communication affected bereavement outcomes for some. The role of the GP was examined and patients responded positively to practical suggestions to improve bereavement care. CONCLUSIONS: Bereavement support was seen to be an important part of the GP role by the majority of those interviewed. As a result recommendations have been made for a protocol to support the newly bereaved.

Aged↗
PubMed1989

Physician ratings of appropriate indications for three procedures: theoretical indications vs indications used in practice.

We previously reported substantial disagreement among expert physician panelists about the appropriateness of performing six medical and surgical procedures for a large number of theoretical indications. A recently completed community-based medical records study of about 4,500 patients who had one of three procedures--coronary angiography, upper gastrointestinal endoscopy, and carotid endarterectomy--shows that many of the theoretical indications are seldom or never used in practice. However, we find that there is also substantial disagreement (5, 25, or 32 per cent for angiography, endoscopy, or endarterectomy, respectively) about the appropriateness of indications used in actual cases if disagreement is defined by first discarding the two extreme of nine ratings, then looking for at least one rating near the bottom (1 to 3) and one near the top (7 to 9) of the 9-point scale. Patients should know that a substantial percentage of procedures are performed for indications about which expert physicians disagree.

Attitude of Health Personnel↗
PubMed1994

Do patients care about the age of their general practitioner? A questionnaire survey in five practices.

BACKGROUND: Previous work has suggested that some patients like their doctors to adopt a paternal or maternal role. AIM: This study set out to establish whether or not patients had preferences with regard to the age of their general practitioner and also to see whether they attributed various characteristics to younger or older doctors. METHOD: A self-administered questionnaire was given to 500 patients attending five general practices in Lothian, Scotland. RESULTS: Significant numbers of patients attributed different characteristics to older or younger doctors. Older doctors were more likely to be attributed positive attributes such as being thorough, kind, and willing to listen. The mean preferred age was 42 years. This varied slightly with the age of patients, from 40 years for patients under the age of 25 years to 45 years for those over 60 years. Of patients, 58% thought the age of their doctor was unimportant, but many were unhappy about seeing very young doctors (20-25 years, n = 195) or old doctors (66-75 years, n = 193). CONCLUSION: Patients did not seem concerned about the age of their doctor as long as he or she was of an age normally practising in the United Kingdom (27-65 years). They had some stereotyped views on the characteristics of older and younger doctors, but these were not held particularly strongly. Patients appeared to want a balance with the doctor being experienced and being up to date.

Adolescent↗
PubMed1997

Endoscopy is not a risk factor for Helicobacter pylori infection--but medical practice is.

BACKGROUND: Previous studies have suggested an increased risk for Helicobacter pylori infection in physicians who perform UGI endoscopy because of exposure to potentially infectious gastric secretions. Therefore, the H. pylori infection status of the endoscopy staff was compared with the H. pylori prevalence of medical staff without endoscopy experience and control subjects who had no contact with patients. METHODS: The noninvasive 13C-urea breath test was performed in 2108 volunteers: 1460 physicians (mean age 44 +/- 12 years), 235 nurses (33 +/- 10 years), and 413 control subjects (43 +/- 12 years) who were not working in clinical medicine. All subjects completed a questionnaire concerning the weekly frequency of gastroscopies and the duration of endoscopic experience. RESULTS: Overall, 37.4% of the physicians and 35.3% of the nurses, but only 27.1% of the control subjects were infected. H. pylori infection was not significantly different between endoscopy-performing (37.8%; n = 1091) and general medical staff (35.9%; n = 604). Neither the frequency of gastroscopies nor the duration of endoscopy practice correlated with H. pylori status. With respect to the age distribution; however, a statistically significant higher prevalence of H. pylori was observed in physicians and nurses compared with the 413 control subjects without patient contact (p < 0.01). CONCLUSION: UGI endoscopy is not a risk factor for H. pylori infection, but medical practice slightly raises H. pylori acquisition.

Adult↗
PubMed2005

The limited effect of screening for depressive symptoms with the PHQ-9 in rural family practices.

CONTEXT: Previous studies have found that routine screening for depression does not improve patient outcome unless it is combined with case management. However, these studies were conducted before the widespread use of SSRIs or in settings other than traditional primary care. PURPOSE: This study investigated whether screening for depressive symptoms improves outcomes for depressed patients seen in rural fee-for-service primary care offices. METHODS: Depression screening was conducted at 2 private rural clinics in Iowa using the PHQ-9. Patients with depressive symptoms were randomized to the control group or the intervention group, where providers were given completed PHQ-9 questionnaires at the baseline visit. The outcome PHQ-9 scores were assessed by telephone at 4, 10, and 24 weeks after the index visit. FINDINGS: A total of 861 patients were screened for depressive symptoms; 51 subjects enrolled in the trial. The intervention and control groups did not significantly differ with respect to changes in PHQ-9 scores at any of the 3 follow-up times. They also did not differ with respect to the proportion of subjects who were actively managed with medication or by referral to a mental health specialist: 46% vs 33% (P = .38) for all subjects and 50% vs 50% (P = .96) for subjects with major depression at baseline. CONCLUSIONS: Screening for depressive symptoms with the PHQ-9 in 2 rural medical clinics did not significantly increase physicians' active management of depression or lead to improved patient outcomes.

Adult↗
PubMed2001

Barriers in the care of patients who have experienced a traumatic event: the perspective of general practice.

BACKGROUND: Previous research has indicated that GPs encounter barriers in the care of patients who have experienced a traumatic event. OBJECTIVES: The aims of the present study were to map barriers GPs encounter in the care of patients who experience a traumatic event and solutions for these barriers, and to estimate the influence of GP characteristics on the number of barriers experienced. METHODS: Telephone interviews were conducted among a sample of 500 Dutch GPs stratified by sex. Topics covered barriers in the care of victims of: accidents, incest in the past, ongoing physical or sexual abuse of adults, and ongoing physical or sexual abuse of children. RESULTS: The response rate was 44%. GPs are regularly confronted with patients who have experienced a traumatic event. GPs experience 10% barriers in care of patients who have difficulties getting over an accident, 13% in the care of incest victims, 16% in the care of adults who are physically or sexually abused, and 20% in the care of physically or sexually abused children. Most of the GPs recently updated their knowledge of care of victims of traumatic events, but still the majority feel in need of additional expert training. CONCLUSION: GPs experience the greatest number of barriers in the care of children who are abused. GP characteristics were not related to the number of barriers. However, seeing more victims was related to fewer barriers. To facilitate GP care of victims of traumatic events, GP training and continuing medical education should focus especially on skills education regarding the detection and initial treatment of traumatic events of ongoing physical or sexual abuse.

Accidents↗
PubMed2003

Physician specialty and quality of care for CHF: different patients or different patterns of practice?

BACKGROUND: Previous reports have suggested that internists employ evidence-based care for congestive heart failure (CHF) less frequently than cardiologists. Reasons for this possible difference are unclear. METHODS: A retrospective review of 185 consecutive patients admitted to a Canadian tertiary care facility between April 1998 and March 1999 with a primary diagnosis of CHF and who were treated by internists (IM group) or cardiologists (CARD group) was conducted. RESULTS: The CARD group (n=65) was younger (70 versus 76 years, P<0.001) and had larger left ventricular end-diastolic diameter by echocardiography (57 versus 51 mm, P=0.006) than the IM group (n=120). The CARD group documented ejection fraction in 90% of cases versus 54% in the IM group (P<0.05). There was no difference in angiotensin-converting enzyme (ACE) inhibitor usage (68% versus 63%, P=0.48) or optimal ACE dosage (CARD 50% versus IM 42%, P=0.44). Multivariate predictors of ACE inhibitor usage were serum creatinine, male sex, peripheral edema and increasing serum glucose. The CARD group had higher usage of beta-blockers (69% versus 49%, P<0.009), lipid lowering medication (35% versus 17%, P<0.004) and warfarin therapy for atrial fibrillation (74% versus 28%, P<0.005). CONCLUSION: The data suggest that Canadian cardiologists and internists use ACE inhibitors equally and care for a relatively similar group of CHF patients. However, beta-blockade, warfarin, lipid lowering therapy and documentation of critical data occurred more frequently under cardiologist care. The possibility that there may be a gradation of adoption of newer guidelines for CHF care according to physician specialty is raised.

Adrenergic beta-Antagonists↗
PubMed2005

Reasons for switching between antipsychotics in daily clinical practice.

BACKGROUND: Previous research that atypical antipsychotics were switched less often compared to typical antipsychotics, suggesting overall better treatment satisfaction. The objective of this study was to investigate the reasons for switching antipsychotics after initiating oral treatment with either typical or atypical antipsychotics in a clinical setting. PATIENTS AND METHODS: A total of 123 patients that switched antipsychotic therapy were recruited from 17 psychiatric hospitals, of which 46 % switched because of lack of effect and 45 % because of adverse effects. RESULTS: No significant differences were found between users of atypical versus typical antipsychotics in reasons for switching, both for overall adverse events, and lack of effect. In users of atypical antipsychotics extrapyramidal effects were reported less often as reason for switching (adjusted OR = 0.18 (95 % CI = (0.07 - 0.51)). Patients on atypical antipsychotics switched more often because of weight gain (adjusted OR = 12.8 (95 % CI = (1.50 - 109)). CONCLUSION: In conclusion, when switching occurred, no difference was found in the frequency of general tolerability or reported lack of effectiveness. However, the type of adverse event as a reason for switching differed between atypical and typical antipsychotics.

Adolescent↗
PubMed2000

Therapy of estrogen receptor-positive micrometastases in the peritoneal cavity with Auger electron-emitting estrogens--theoretical and practical considerations.

Previous studies have demonstrated that Auger electron-emitting estrogens, when associated with the estrogen receptor (ER), can effect breaks in DNA and ER-dependent radiotoxicity. To evaluate the potential of [123I]-iodoestrogens, ([123I]-IE) to treat ER-positive human cancer cells, we have studied the effect of incubation of [123I]-IE with ER-positive MCF-7 breast cancer cells on cell survival in vitro and found that subnanomolar concentrations of [123I]-IE effectively reduce survival, with a mean lethal dose of about 800 decays per cell. MCF-7 cells incubated 30 min with 2 nM [123I]-IE (13 MBq/ml) showed a 2 log reduction in the ability to form tumors in immunodeficient mice. Evaluation of a mathematical model for [123I]-IE therapy for intraperitoneal micrometases in vivo in the mouse, based on variables related to the (a) specific activity of [123I]-IE; (b) its affinity for ER; (c) the characteristics of the uptake and retention of [123I]-IE by the target cells; (d) the concentration of ER in the tumor cells and (e) the tumor weight suggest that such therapy may be feasible.

Animals↗
PubMed1998

Computer-aided analysis of conditions for optimizing practical electrorotation.

Previous studies have indicated that the variations in torque induced in particles in electrorotation electrode arrays are sufficiently large to cause errors in electrorotation measurements. In order to avoid this, experimenters usually study particles bounded by an arbitrary region near the centre of the electrodes. By simulating the time-dependent electric field for polynomial electrodes, we have assessed the variation in torque across the centre of the array. By considering both the variation in applied torque and the dielectrophoretic force in the electrode chamber, the optimal conditions for electrorotation experiments have been determined. Further to this, by comparing the torque variation across the electrode chamber for a number of common electrode designs, a comparison of the suitability of each electrode design for multiparticle electrorotation analysis has been made.

Computer Simulation↗
PubMed2001

The Knee Society Index of Severity for failed total knee arthroplasty: practical application.

Previous classifications of severity for total knee arthroplasty revisions have been based largely on bone loss of the femur and tibia. These approaches failed to address the more technically difficult issues in revision surgery such as surgical exposure, contractures, extremity alignment, implant removal, soft tissue stability (in the anteroposterior and in the sagittal planes), extensor mechanism integrity, and patellar revisability. Through the Knee Society, the authors developed a severity index that incorporated these latter factors into one measure. The current authors describe the application of the Knee Society Index of Severity for failed total knee arthroplasty and its method of scoring.

Arthroplasty, Replacement, Knee↗
PubMed2006

The response to challenging behaviour by care staff: emotional responses, attributions of cause and observations of practice.

BACKGROUND: Previous studies have attempted to apply Weiner's attributional model of helping behaviour to care staff who work with service users with intellectual disabilities and challenging behaviours by using studies based on vignettes. The aims of the current study were to investigate the application of Weiner's model to 'real' service users with intellectual disabilities and challenging behaviours and to observe the care staff's actual responses to challenging behaviours displayed by service users. Also, to compare care staff attributions, emotions, optimism, willingness to help and observed helping behaviours for self-injurious behaviours in comparison to other forms of challenging behaviours. METHOD: A total of 27 care staff completed two sets of measures, one set regarding a self-injurious behaviour and the other regarding other forms of challenging behaviour. An additional 16 staff completed one set of measures. The measures focused on care staff attributions, emotions, optimism and willingness to help. Also, 16 of the care staff were observed interacting with the service users to collect data regarding their responses to challenging behaviours. RESULTS: For both self-injurious behaviours and other forms of challenging behaviour, associations were found between the care staff internal, stable and uncontrollable attribution scores and care staff negative emotion scores. However, no associations were found between the care staff levels of emotion, optimism and willingness to help. Some associations were found between the care staff levels of willingness to help and observed helping behaviours. There were significant differences between the care staff attribution scores with higher scores being obtained for uncontrollable and stable attributions for other forms of challenging behaviours. No significant differences were found between the care staff emotions, optimism, willingness to help and observed helping behaviours. CONCLUSIONS: The results did not provide support for Weiner's attributional model of helping behaviour. However, a preliminary model of negative care staff behaviour was derived from the exploratory analyses completed. This model proposes that there are associations between internal, stable and uncontrollable attributions and negative emotions in care staff and also between negative emotions and negative behaviours displayed by care staff in response to the actions of service users.

Adult↗
PubMed1999

Effectiveness of cognitive therapy for delusions in routine clinical practice.

BACKGROUND: Previous studies have suggested that cognitive therapy is effective in modifying delusions. AIMS: To assess the effectiveness of cognitive therapy on patients seen in routine clinical work. METHOD: Eighteen patients with chronic delusions were treated using cognitive therapy, after the method of Chadwick and Lowe. A single-case multiple-baseline experimental design was used, including a control treatment. Each subject was used as their own control. RESULTS: Six patients reduced conviction in their delusions during cognitive therapy and not during the control treatment. Seven patients' conviction ratings did not change. Five patients showed a variable response. Degree of conviction did not fall to zero in any patient. All patients reported that the therapy had been helpful; six spontaneously mentioned changes in psychotic thinking. CONCLUSIONS: One-third of patients with chronic delusions whom we treated responded to delusion modification with a reduction in degree of belief. Change within therapy sessions predicted outcome, as did variation in the conviction during baseline. Cognitive therapy with delusions should aim at reducing distress as well as conviction.

Case-Control Studies↗
PubMed2002

Protocols for the dosimetry of high-energy photon and electron beams: a comparison of the IAEA TRS-398 and previous international codes of practice. International Atomic Energy Agency.

A new international Code of Practice for radiotherapy dosimetry co-sponsored by several international organizations has been published by the IAEA, TRS-398. It is based on standards of absorbed dose to water, whereas previous protocols (TRS-381 and TRS-277) were based on air kerma standards. To estimate the changes in beam calibration caused by the introduction of TRS-398, a detailed experimental comparison of the dose determination in reference conditions in high-energy photon and electron beams has been made using the different IAEA protocols. A summary of the formulation and reference conditions in the various Codes of Practice, as well as of their basic data, is presented first. Accurate measurements have been made in 25 photon and electron beams from 10 clinical accelerators using 12 different cylindrical and plane-parallel chambers, and dose ratios under different conditions of TRS-398 to the other protocols determined. A strict step-by-step checklist was followed by the two participating clinical institutions to ascertain that the resulting calculations agreed within tenths of a per cent. The maximum differences found between TRS-398 and the previous Codes of Practice TRS-277 (2nd edn) and TRS-381 are of the order of 1.5-2.0%. TRS-398 yields absorbed doses larger than the previous protocols, around 1.0% for photons (TRS-277) and for electrons (TRS-381 and TRS-277) when plane-parallel chambers are cross-calibrated. For the Markus chamber, results show a very large variation, although a fortuitous cancellation of the old stopping powers with the ND,w/NK ratios makes the overall discrepancy between TRS-398 and TRS-277 in this case smaller than for well-guarded plane-parallel chambers. Chambers of the Roos-type with a 60Co ND,w calibration yield the maximum discrepancy in absorbed dose, which varies between 1.0% and 1.5% for TRS-381 and between 1.5% and 2.0% for TRS-277. Photon beam calibrations using directly measured or calculated TPR20,10 from a percentage dose data at SSD = 100 cm were found to be indistinguishable. Considering that approximately 0.8% of the differences between TRS-398 and the NK-based protocols are caused by the change to the new type of standards, the remaining difference in absolute dose is due either to a close similarity in basic data or to a fortuitous cancellation of the discrepancies in data and type of chamber calibration. It is emphasized that the NK-ND,air and ND,w formalisms have very similar uncertainty when the same criteria are used for both procedures. Arguments are provided in support of the recommendation for a change in reference dosimetry based on standards of absorbed dose to water.

Air↗
PubMedDate not supplied

Medical student evaluation of family nurse practitioners as teachers.

BACKGROUND: Demands on family medicine faculty to generate clinical revenue may negatively impact the undergraduate medical education program. To minimize this possibility and better model interprofessional education, family nurse practitioners (FNPs) were hired as clinicians and teachers as part of a longitudinal family medicine clerkship. This paper reports the results of a pilot study of student evaluations of nurse practitioner teaching. METHODS: All M3 and M4 students were asked to evaluate one of three FNPs who had precepted them multiple times during their previous year of ambulatory care practice. Two previously studied closed-ended questionnaires were used to assess quality of teaching by the FNPs. Students also responded to a series of open-ended questions. RESULTS: Ninety-one percent of 97 students responded to the survey. Responses to the closed-ended questions as well as comments by the students and physicians were positive regarding the teaching by FNPs. The teaching skills most highly regarded by the students tended to be different than those most highly regarded in physicians. CONCLUSIONS: This pilot study suggests FNPs can be successfully integrated into undergraduate medical education settings, offering teaching strengths that complement those of physicians. Integrating the two professions in a family medicine clerkship may prove beneficial to students and expand departmental teaching resources without further straining finances. Efforts at evaluating the teaching contributions of FNPs at other institutions are needed to substantiate the present study results.

Ambulatory Care↗
PubMed2006

Gas cooking, kitchen ventilation, and exposure to combustion products.

We evaluated a questionnaire-based system for classifying homes into groups with distinctly different chances of accumulating combustion products from cooking appliances. The system was based on questions about type of cooking appliance, type and use of ventilation provisions, and kitchen size. Real-time measurements were made of CO, CO(2), temperature, and water vapor, and passive sampling was performed of nitrogen oxides, over a week-long period in 74 kitchens. During the measurements, inhabitants kept a diary to record appliance use time and use of ventilation provisions. The questionnaire-based and diary-based home classifications for the 'Chance of Accumulation of Combustion Products' (CACP) turned out to agree fairly well. For CO(2) as well as for CO a significant difference between the 'high' and 'low' CACP groups was found for the mean accumulation in the kitchen during cooking of the combustion generated concentrations. These facts are considered to be important experimental evidence of the CACP stratification being valid for our study population. In the homes studied, NO(2) as well as CO concentrations were found to be lower compared with previous studies in The Netherlands. Practical Implications Previous studies on indoor combustion product dispersal conducted in the early- to mid-1980s in the Netherlands showed much higher NO(2) and CO concentrations than the present study. Apparently, the removal of combustion products formed during cooking is more efficient in the (mostly newer) homes that we studied than in the homes studied in the early- to mid-1980s. More detailed knowledge of kitchen situations is needed to improve the CACP model. Future studies can achieve this by using questionnaires on the kitchen situation, diaries and real-time measurements of the combustion products under consideration.

Air Pollution, Indoor↗