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PubMed2001

Medically unexplained symptoms--GPs' attitudes towards their cause and management.

BACKGROUND: Medically unexplained physical symptoms present one of the most common problems in modern medical practice but often prove difficult to manage. The central position of the GP in the care of patients with medically unexplained symptoms has been emphasized repeatedly, but little is known about the attitudes of GPs to this role. Understanding how GPs view these patients may inform the development of effective strategies for management. OBJECTIVE: Our aim was to survey the attitudes of UK GPs towards medically unexplained symptoms (MUS) and somatization. METHODS: A random sample of 400 GPs in the South Thames (West) region were surveyed using a postal questionnaire. Respondents' attitudes toward the cause and management of MUS were recorded. RESULTS: A total of 284 completed questionnaires were returned (22 returned incomplete), giving an adjusted response rate of 75%. Although it was broadly felt that patients with MUS are difficult to manage, most GPs felt that patients with MUS should be managed in primary care. Providing reassurance, counselling and acting as a 'gatekeeper' to prevent inappropriate investigations were considered important roles for GP management. A majority felt that patients with MUS have personality problems or psychiatric illness. Fewer than half of the respondents felt that there are effective treatments available for somatization. CONCLUSION: GPs consider the management of patients with MUS to be an important part of their workload, but there is a perception that effective management strategies are lacking. Psychiatrists need to offer greater support and training for GPs in this area of health care.

Adult↗
PubMed2002

Striking the right balance in colorectal cancer care--a qualitative study of rural and urban patients.

BACKGROUND: Colorectal cancer is the second most common cause of cancer-related death in Scotland. For patients, the journey from diagnosis through treatment is complex and there are inequalities in survival rates. OBJECTIVES: The aim of the present study was to explore how patients with colorectal cancer perceive their care. METHODS: This was a qualitative study involving 95 patients and relatives of patients with colorectal cancer in the North, Northeast and Northern Isles, Scotland. Focus groups (32 participants) were conducted in hospital, and interviews (63 participants) in patients' own homes in order to explore their experiences of health services for cancer-what was good, what was bad and what was needed. Analysis was inductive, with exploration of similar and divergent perspectives within themes. RESULTS: Patients wanted rapid diagnosis, specialist treatment and good communication, but their experiences of and perspectives on these areas were often divergent. Delays in diagnosis could stem from late presentation by patients, but also from early presentation when the cancer could go undetected. GP continuity was desirable, but sometimes implicated in delays. Patients preferred their GPs to be advocates, not gatekeepers. The context, however, was one where some patients pursued their care tenaciously while others did not. For some, speed of progress through the system was everything, but others found this could be impersonal. Outlying patients had to balance transport difficulties with the benefits of distant specialist treatment. Some patients wanted full information to be provided directly, but others could not cope with this. CONCLUSIONS: From patients' perspectives, ideal cancer care cannot be achieved in a uniform way. For some of the key goals of cancer treatment to be met, including rapid access to specialist treatment for all and good communication of bad news and test results, a balance must be struck which tailors care to individuals.

Adult↗
PubMed2003

Referral for genetic counselling during pregnancy: limited alertness and awareness about genetic risk factors among GPs.

BACKGROUND: In many countries, GPs play a key role in the referral to other medical specialists. Referral for reproductive genetic counselling during a pregnancy of women with a genetic risk factor already present before pregnancy has many disadvantages. Nevertheless, some 10-20% of the counsellees who attend a Department of Clinical Genetics for the first time are pregnant. OBJECTIVES: We aimed to explore the role of the GP in referring women for genetic counselling during, instead of before a pregnancy. METHOD: The GPs of 100 pregnant women who received genetic counselling were invited to participate in the study and asked to complete a questionnaire. The topics were: initiation and discussion of aspects of referral to the Department of Clinical Genetics; reasons for the referral during, instead of before a pregnancy; knowledge of genetic counselling; attitudes towards genetic counselling before a pregnancy; and attitudes towards abortion. RESULTS: To our surprise, 29% of the GPs indicated that they had not been involved in the referral to the Department of Clinical Genetics at all. Furthermore, the referral was initiated by the patient herself in most cases (40%) and by the GPs in 31% of the cases. Of the GPs who were involved in the referral, most of them (79%) talked to their patients to different extents about what to expect from their visit to the Department of Clinical Genetics; however, potential choices after an adverse outcome at prenatal diagnosis were discussed less often (60%). The main reason for referring the patient during, instead of before her pregnancy was because the GP was unaware of a potential risk factor before pregnancy (71%) and, consequently, never had a chance to talk about a referral before (71%). Other reasons for referral during pregnancy mentioned by the GPs were reassuring the patient about the health of her unborn child (32%) and the wish of the patient to be referred during pregnancy (31%). GPs considered their knowledge of clinical genetics to be limited (mean score 5, on a scale from 0 to 10). The majority of the GPs were in favour of genetic counselling taking place before, instead of during pregnancy, and they had no great objections to abortion. CONCLUSIONS: During pregnancy, the gatekeeper function of the GP in the referral for genetic counselling is undermined. Limited alertness and awareness among GPs about genetic risk factors in their patients played a major role in this undermined function and in the less appropriate timing of referral. Neither insufficient knowledge nor barriers to acceptance explained this lack of alertness and awareness. We advocate the implementation of routine family history taking in general practice.

Chi-Square Distribution↗
PubMed2004

Abusive behaviour experienced by primary care receptionists: a cross-sectional survey.

BACKGROUND: Receptionists act as gatekeepers to GPs, and thus are often placed in situations of conflict. However, there is a lack of research in this area. OBJECTIVE: The purpose of this study was to identify the incidence and associations of verbal and physical abuse against primary care receptionists, both pre- and post-'zero tolerance'. METHODS: A postal questionnaire was designed, piloted and sent to all reception staff in 50 randomly selected general practices in Leeds. The primary purpose was to identify any verbal or physical abuse experienced in the 12 months prior to the survey and assess the association between abuse experienced and deprivation. RESULTS: Seventy percent of receptionists completed and returned the questionnaire. Over two-thirds of receptionists had experienced verbal abuse in the last year. During the same time period, 60% reported telephone abuse and 55% reported face to face abuse. The incidence of abuse was higher in the year prior to the study than in the preceding period. Practice deprivation was identified as a significant factor for verbal abuse (P = 0.003). CONCLUSION: Verbal abuse against receptionists is significantly associated with the level of deprivation of the practice area. There is no evidence that 'zero tolerance' led to a reduction in abuse experienced by primary care receptionists. All primary care receptionists should receive adequate training on managing abuse.

Adult↗
PubMed2004

Less haste more speed: factors that prolong the interval from presentation to diagnosis in some cancers.

BACKGROUND: In the UK, the GP is the gatekeeper to specialist services in addition to many other roles. Recently, the GP is also expected to select cases that warrant 'urgent' as opposed to 'routine' specialist investigation. Failure to refer on the appropriate timetable may have implications for timely diagnosis. OBJECTIVE: Our aim was to explore the circumstances in which the diagnosis of cancer is delayed with reference to the primary care records and by a structured investigation of clinical records in one practice. METHODS: The study was set in an urban group practice serving a mixed population of deprived and affluent communities. List size was 10 440 patients, with five whole time equivalent partners and three practice nurses. The appointment system was fully computerized and there were no personal lists. Records for all cases with specified common cancers diagnosed since 1990 and still registered in the practice were reviewed. The interval from presentation to referral, referral to diagnosis and presentation to diagnosis was compared for a series of factors including 'urgent' referral. The clinical team currently working in the practice conducted a structured review of the case records for the most delayed cases. RESULTS: Fifty-four cases were listed in the practice. A series of factors were identified as having a bearing on delayed diagnosis, including a reticence on the part of patients to seek to expedite specialist appointments, failures of communication, and patients presenting multiple problems in short general practice consultations. The action plan agreed by the clinical team includes improving the quality of communication with secondary care, follow-up of patients who have been referred for radiological or ultrasound investigation and reviewing patients who fail to attend specialist clinics. CONCLUSIONS: The data imply that delays sometimes result from avoidable errors before and after referral and especially by the patient entering secondary care on the wrong pathway. Improving the patients' experience in health care requires the provider to take a global view of the service. Primary care is not merely a filter but influences and is influenced by policies in other parts of the health care system.

Family Practice↗
PubMed2005

Do patients want to disclose psychological problems to GPs?

BACKGROUND: GPs are an accessible health care provider for most patients with mental disorders and are gatekeepers to specialist care. The extent to which patients consider their primary care team as relevant to their mental health problems needs to be explored. OBJECTIVES: To explore reasons why patients choose not to disclose psychological problems to GPs, and to discuss the implications for the provision of primary mental health care. METHODS: A cross-sectional survey of consecutive patients attending general practices in New Zealand (part of the MaGPIe study). Patients were screened using the GHQ-12 and a stratified sample participated in a structured in-depth interview to assess their psychological health. Non-disclosure of psychological problems was explored. GPs assessed patients' psychological health using a 5-point scale of severity. RESULTS: Seventy GPs (90%) and 775 patients (70%) participated. Overall, 29.8% of all patients and 36.9% of patients with current symptoms reported non-disclosure of self-perceived psychological problems. Younger patients, those consulting more frequently and those with greater psychiatric disability were more likely to report non-disclosure. The most frequently given reasons were beliefs that a GP is not the 'right' person to talk to (33.8%) or that mental health problems should not be discussed at all (27.6%). CONCLUSIONS: Interventions such as screening and GP education may be ineffective in improving primary mental health care unless accompanied by educational programmes for the general public to increase mental health literacy, de-stigmatise mental illness and increase awareness of general practice as an appropriate and effective source of health care.

Adolescent↗
PubMed2005

Family caregiver research and the HIPAA factor.

Research in family caregiving recently has become more challenging because of the strict protection of privacy mandated in the Health Insurance Portability and Accountability Act (HIPAA) of 1996. We ask when should Institutional Review Boards (IRBs) follow HIPAA rules to the letter and when might they use the waiver option? What is the appropriate balance between the goals of protecting the privacy of patients' personal health information and facilitating family-caregiver research that may benefit them and others? More particularly, should patients be gatekeepers for caregiver participation in minimal-risk research? We describe one approach that successfully met HIPAA criteria and also allowed high-quality research. In developing protocols and applying for IRB approval, researchers must be as familiar with HIPAA regulations as they are with IRB standards. Finally, we recommend changes in the review process that may facilitate research efforts with family caregivers while protecting important privacy interests.

Brain Injuries↗
PubMed2002

Evaluation of a workplace cardiovascular health promotion programme in the Republic of Ireland.

This paper describes a comprehensive evaluation of the organizational impact of a workplace health promotion programme, in the context of a framework devised by Nutbeam in 1998. The Happy Heart at Work programme, sponsored by the Irish Heart Foundation, has been in existence for 10 years and aims to promote a healthy lifestyle through specially devised modular materials. A postal census survey of 785 valid registered sites expressing any level of initial interest in the programme yielded a 40% response rate (n = 311). Of these, 194 (63%) were currently active and 114 were not. Active organizations were less likely to be Irish owned (54.5% versus 71.4%, p < 0.05), and more likely to operate in shifts (72.3% versus 51.1%, p < 0.05) or to have an occupational physician amongst the staff (36.9% versus 31%). Programme impact within active organizations, based on pre-defined Health Promoting Workplace parameters, was documented. There was agreement in the questionnaire responses that participating organizations promote a smoke-free environment (mean rating on five-point scale = 4.42), employee health and well-being (4.21) and good nutritional practice (4.11). Triangulation of research methods, including a telephone survey of gatekeepers from within organizations (n = 18), focus groups with participant employees (n = 42) and a review of the staff opinions of the facilitating organization on the programme, all showed strong concordance with respect to the strengths and weaknesses of Happy Heart at Work. The programme was felt to help improve employees' lifestyle habits and morale, as well as the company's public image. The main drawbacks of the programme were its relatively low profile, even in actively participating organizations, and the fact that it was not seen to be independently sustainable without intensive and ongoing support.

Cardiovascular Diseases↗
PubMed1991

Responding to psychosocial needs: physician perceptions of their referral practices for hospitalized patients.

Physicians play a critical gatekeeping function related to psychosocial problem identification and subsequent referral to appropriate hospital or community services. Thirty physicians on staff at a moderate-size, multiservice medical facility were interviewed to determine their perceptions regarding identification of and referral rates for psychosocial problems of their hospitalized patients. In addition to raising questions for further investigation, this article provides a useful structure for gathering data for use by hospital social work departments in developing strategies to enhance physicians' collaboration with hospital social workers.

Attitude of Health Personnel↗
PubMed2005

Secretion of cytokines and chemokines by polarized human epithelial cells from the female reproductive tract.

BACKGROUND: Pro-inflammatory chemokines that attract and cytokines that activate immune cells contribute to normal physiological homeostasis in the female reproductive tract, and are needed to deal effectively with potential pathogenic microbes. Mucosal epithelial cells are capable of producing these factors that communicate with cells of the innate and adaptive immune systems. METHODS: Epithelial cells from Fallopian tube, endometrium and endocervix were isolated and grown to high transepithelial resistance in cell inserts from seven patients who had hysterectomies. Interleukin (IL)-8, IL-6, granulocyte colony-stimulating factor (G-CSF), monocyte chemoattractant protein-1 (MCP-1), granulocyte-macrophage colony-stimulating factor (GM-CSF), tumour necrosis factor-alpha (TNF-alpha) and macrophage inflammatory peptide-1beta (MIP-1beta) were assessed by Luminex bead analysis or enzyme-linked immunosorbent assay (ELISA) in epithelial cell conditioned media from the apical and basolateral compartments. RESULTS: With the exception of MCP-1, the seven chemokines/cytokines constitutively produced by the polarized epithelial cells were preferentially secreted apically. A concentration pattern was found in all cases, with IL-8 and IL-6 produced in the greatest quantity. CONCLUSIONS: The concentrations of IL-8, IL-6, G-CSF and MCP-1 are similar to the levels found in reproductive tract fluids of patients with infection. The constitutive secretion and compartmentalization of large quantities of bioactive chemokines and cytokines provide additional evidence for the role of epithelial cells as gatekeepers of innate immune protection in the female reproductive tract.

Cell Polarity↗
PubMed2006

GPR54 and kisspeptin in reproduction.

Kisspeptins, the peptide products of the KiSS-1 gene, were identified in 2001 as natural ligands of the previously orphan G protein-coupled receptor, GPR54. They include, among others, metastin and kisspeptin-10. The known biological functions of kisspeptins were initially restricted to their ability to suppress tumour metastasis, hence the name of metastin. However, in late 2003, two groups independently reported that loss-of-function mutations of the GPR54 gene are linked to absence of puberty onset and hypogonadotrophic hypogonadism in humans--a phenotype that was reproduced in GPR54-null mice. Those seminal observations revealed a totally unexpected, fundamental role of the KiSS-1/GPR54 system in control of puberty and reproductive function and boosted an extraordinary interest for the characterization of these novel facets of kisspeptin physiology. Indeed, in the last 2 years, metastin and kisspeptin-10 have been demonstrated as very potent stimulators of the gonadotrophic axis, in a number of species and through different routes of administration. In addition, the hypothalamic KiSS-1/GPR54 system has been proven as an essential gatekeeper of GnRH neurons, involved in their activation at puberty and their regulation by gonadal steroids and (probably) metabolic factors. This review comprehensively examines the experimental evidence obtained to date supporting a pivotal role of kisspeptins and GPR54 in the control of reproduction.

Animals↗
PubMed1998

Competition through physician-managed care: the case for capitated multispecialty group practices.

The dominant managed care model in the USA is the individual practice association (IPA), in which physicians in separate practices contract with a health plan. One alternative model, the capitated multispecialty group practice (CMGP), has some distinct advantages: (i) the best randomized trial comparing a health management organization (HMO) with indemnity insurance showed equivalent health outcomes for a prepaid group-practice model HMO, with about a 40% saving in cost, mostly from lower hospital utilization. There is no comparable evidence for IPA-style HMO's; (ii) most managed care plans control costs through 'gatekeeper' primary care physicians or capitated payment. Strong financial disincentives to care, applied to small practices, lead to a significant risk of withholding needed care. Large capitated groups diffuse the risk among hundreds or thousands of physicians; (iii) small practices also lack the financial resources and expertise to develop information systems, continuous quality improvement programs, and other means of improving efficiency. Larger groups can integrate specialty and primary care, laboratory, pharmacy, information technology and other services, to improve quality and cost-effectiveness, while maintaining physician control of the process; (iv) in urban California, HMO enrollment in six large capitated groups increased by 91% from 1990 to 1994. Hospital utilization for these groups was less than half the USA average; (v) because it is self-insured, the CMGP could contract directly with purchasers, eliminating the need for the insurance intermediary. The CGMP offers an ethical, effective alternative that maintains the primacy of the physician in health care: physician-managed care.

California↗
PubMed1990

Establishing the moral basis of medicine: Edmund D. Pellegrino's philosophy of medicine.

Edmund D. Pellegrino's philosophy of medicine is explored in categories such as the motivation in constructing a philosophy of medicine, the method, the starting point of the doctor-patient relationship, negotiation about values in this relationship, the goal of the relationship, the moral basis of medicine, and additional concerns in the relationship (concerns such as gatekeeping, philosophical anthropology, axiology, philosophy of the body, and the general disjunction between science and morals). A critique of this philosophy is presented in the following areas: methodology, relation to ontology and sociology, the dynamic of individual and social concerns, and the new social condition of medicine. Finally, some suggestions for the future revitalization of philosophy of medicine are made based on Pellegrino's ideas. The focus throughout is on the moral basis and moral consequences of the philosophy of medicine, and not on other important themes.

Beneficence↗
PubMed2001

Dietary supplement use: consumer characteristics and interests.

Four major issues should be considered in a discussion of what consumers need to know about supplements and herbal treatments. 1) Usage of supplements is changing as consumers are taking charge of their health and seeking alternative forms of medicine (Eisenberg et al. 1998, Gilbert 1999 ). 2) The characteristics of supplement users have been profiled in numerous academic and industrial surveys. However, even the best models based on consumers' characteristics can predict < 30% of diet-related behavior (Baranowski et al. 1999 ). 3) Experts in traditional medicine and nutrition lack information on supplements and herbals. The Practice and Policy Guidelines Panel of the National Institute of Health Office of Alternative Medicine (1997) stated that practices used in complementary and alternative medicine were "unsuitable for the development of evidence-based practice guidelines." Well-designed basic and clinical research is needed on the efficacy, bioavailability and safety of supplements and herbal medications. 4) It is debatable which agencies and professionals are the best gatekeepers of information on supplements and herbals. Significant numbers of consumers do not seem to rely on their physicians for information on alternative forms of medicine (Eisenberg 1997 ). Despite the obstacles, the traditional medical community (including nutritionists) should focus more research efforts on diet supplements and herbal treatments and increase training on these topics for students majoring in health care fields. Then health care professionals can mount high quality, targeted education programs for consumers.

Community Participation↗
PubMed2006

Status of p53 in first-trimester cytotrophoblastic cells.

p53 has been called the cellular gatekeeper of the genome because it can induce cell-cycle arrest in G1, apoptosis or affect DNA replication in response to DNA damage. As p53 has been observed in first-trimester cytotrophoblastic cells (CTB), but its expression in normal cells is generally not detectable because of its short half-life, p53 could play an important role in cellular differentiation and/or in the control of the invasion of trophoblastic cells; therefore, p53 status was investigated in these cells. Using different antibodies recognizing different epitopes of p53 protein, abundant p53 expression was observed both in nuclear and in cytoplasmic compartments of first-trimester CTB. Whereas p53 was detected in the nuclei of few trophoblastic cells with an antibody recognizing the N-terminal epitope of the protein, high expression level of p53 in the cytoplasm of CTB was detected with an antibody recognizing the middle part of p53. The lack of immunoreactivity of p53 with antibodies recognizing the epitopes located at the N-terminus of p53 and the high level of p53 protein observed in the cytoplasm of CTB suggest that the N-terminus of p53 is involved in the formation of complexes. These cytoplasmic complexes were detected under non-reducing conditions in western blot analysis and had apparent molecular weights (MW) of 195, 167 or 125 kDa. These complexes could prolong the half-life of p53 in the cytoplasm of CTBs. By contrast, in the nuclei of CTBs, p53 seems to be present as a tetramer.

Cells, Cultured↗
PubMed2002

The Fanconi anaemia genome stability and tumour suppressor network.

Fanconi anaemia (FA) is a rare autosomal recessive disease characterized by increased spontaneous and DNA crosslinker-induced chromosome instability, progressive pancytopenia and cancer susceptibility. An increasing number of genes are involved in FA, including the breast cancer susceptibility gene BRCA2. Five of the FA proteins (FANCA, FANCC, FANCE, FANCF and FANCG) assemble in a complex that is required for FANCD2 activation in response to DNA crosslinks. Active FANCD2 then interacts with BRCA1 and forms discrete nuclear foci. FANCD2 is independently phosphorylated by ATM (the protein whose gene is mutated in ataxia telangiectasia) in response to ionizing radiation. In addition, the FA proteins are interconnected with other nuclear and cytoplasmic factors all related to cellular responses to carcinogenic stress and to caretaker and gatekeeper functions. In this review, the most recently published data on the molecular biology of the FA pathway and its molecular crosstalk with ATM, BRCA1 and BRCA2, proteins involved in xenobiotic and reactive oxygen species metabolism, apoptosis, cell cycle control and telomere stability, are summarized. The currently available data indicate that FA is a central node in a complex nuclear and cytoplasmic network of tumour suppressor and genome stability pathways fully committed to prevent cancer.

Apoptosis↗
PubMed2003

Rad52 and Ku bind to different DNA structures produced early in double-strand break repair.

DNA double-strand breaks are repaired by one of two main pathways, non-homologous end joining or homologous recombination. A competition for binding to DNA ends by Ku and Rad52, proteins required for non-homologous end joining and homologous recombination, respectively, has been proposed to determine the choice of repair pathway. In order to test this idea directly, we compared Ku and human Rad52 binding to different DNA substrates. How ever, we found no evidence that these proteins would compete for binding to the same broken DNA ends. Ku bound preferentially to DNA with free ends. Under the same conditions, Rad52 did not bind preferentially to DNA ends. Using a series of defined substrates we showed that it is single-stranded DNA and not DNA ends that were preferentially bound by Rad52. In addition, Rad52 aggregated DNA, bringing different single-stranded DNAs in close proximity. This activity was independent of the presence of DNA ends and of the ability of the single-stranded sequences to form extensive base pairs. Based on these DNA binding characteristics it is unlikely that Rad52 and Ku compete as 'gatekeepers' of different DNA double-strand break repair pathways. Rather, they interact with different DNA substrates produced early in DNA double-strand break repair.

Animals↗
PubMed1999

The Janus-faced aspect of 'dry weight'.

BACKGROUND: The goal of haemodialysis treatment in end-stage renal disease (ESRD) patients is to correct the complications of the uraemic condition. Among the main complications are fluid overload and subsequent hypertension that are corrected by achievement of 'dry weight'. We report in this study the evolution of post-dialysis body-weight and blood pressure in patients who began their HD treatment in our unit. METHODS: We studied the monthly evolution of post-dialysis body-weight (expressed as a percentage of pre-dialysis body-weight at the first HD treatment) and predialysis mean arterial pressure (MAP) over 24 months in 61 patients (21 females, mean age 59.8 years; 20% diabetic), treated with cellulosic membranes for 8 h, 3 times a week. RESULTS: The post-dialysis body-weight decreased between the onset of HD and month 2 (M2) (-4.40+/-0.52%). Then it went up, reaching -1.56+/-0.96% at M6, +0.3+/-1.27% at M12, +1.27+/-1.38% at M18 and +1.64+/-1.33% at M24. The post-dialysis body-weight increased by 6% between M2 and M24. The mean arterial pressure (MAP) decreased from 111.3+/-2.5 mmHg at M0 to 94.4+/-1.7 at M6, and then remained stable after M6. Between M2 and M6 the post-dialysis body-weight increased, whereas the predialysis MAP continued to decline. The incidence of hypotension episodes was maximal during the first 4 months of HD treatment. CONCLUSIONS: After the second month of dialysis treatment, the simultaneous increase of post-dialysis body-weight and decrease of pre-dialysis MAP are related to the effects of two processes, i.e. increased weight as the result of anabolism induced by the HD treatment on the one hand and normalization of blood pressure by fluid removal on the other. Continuous clinical assessment of the patient is necessary to provide adequate prescription of post-dialysis body-weight. During the first months of HD treatment, the nephrologist, like Janus, is a double-faced gatekeeper: he must be willing to decrease post-dialysis weight to achieve 'dry weight' and to normalize blood pressure, but he must also be prepared to increase it to compensate for anabolism and to avoid episodes of hypotension.

Analysis of Variance↗