The association between believing staying active is beneficial and achieving a clinically relevant functional improvement after 52 weeks: a prospective cohort study of patients with chronic low back pain in secondary care.

BACKGROUND: According to clinical guidelines, advice to stay active despite experiencing pain is recommended to patients with non-specific low back pain (LBP). However, not all patients receive guideline-concordant information and advice, and some patients still believe that activity avoidance will help them recover. The purpose was to study whether guideline-concordant beliefs among patients and other explanatory variables were associated with recovery. The main aim was to investigate whether believing staying active despite having pain is associated with a better functional outcome. METHODS: This was a prospective cohort study involving adults with non-specific LBP referred from general practices to the Spine Centre at Silkeborg Regional Hospital, Denmark. Patients reported on their beliefs about the importance of finding the cause, the importance of diagnostic imaging, perceiving to have received advice to stay active, pain duration, pain intensity, and STarT Back Tool. Agreeing to: 'An increase in pain is an indication that I should stop what I'm doing until the pain decreases' adjusted for age, gender, and education level was the primary explanatory analysis. A 30% improvement in the Roland Morris Disability Questionnaire (RMDQ) score after 52 weeks was the outcome. RESULTS: 816 patients were included and 596 (73.0%) agreed that pain is a warning signal to stop being active. Among patients not considering pain as a warning signal, 80 (43.2%) had a favourable functional improvement of ≥30% on the RMDQ compared to 201 (41.2%) among patients considering pain a warning signal. No difference was found between the two groups (adjusted P = 0.542 and unadjusted P = 0.629). However, STarT Back Tool high-risk patients had a less favourable functional outcome (adjusted P = 0.003 and unadjusted P = 0.002). Chronic pain was associated with less favourable functional outcome (adjusted P < 0.001 and unadjusted P < 0.001), whereas beliefs about finding the cause, diagnostic imaging, perceiving to have received advice to stay active, or pain intensity were not significantly associated with outcome. CONCLUSIONS: Holding the single belief that pain is a warning signal to stop being active was not associated with functional outcome. However, patients characterised by having multiple psychological barriers (high-risk according to the STarT Back Tool) had a less favourable functional outcome. TRIAL REGISTRATION: Registered at ClinicalTrials.gov (registration number: NCT03058315), 20 February 2017.

Paediatric respiratory isolation: A challenge for a secondary care hospital! A service innovation project.

OBJECTIVE: The aim of this project was to broaden the secondary care hospital's scope of services and provide safe, effective and quality care for the patient presenting with measles. METHODS: Six Sigma DMAIC [define measure, analyze, improve, and control (DMAIC)] methodology was used in this quality improvement project. The quality project was started in October 2015 using a Gantt chart quality tool. RESULTS: The paediatric team with the support of administration of the hospital has established isolation rooms and devised a policy for the care and management of patient with airborne infection to avoid cross transmission. During six months period after establishment of isolation room there were sixty two suspected or confirmed measles cases who were admitted in our hospital, out of them only 4(6.4%) of patients were referred because of their sick condition and need of ventilator support. Further, the percentage of patient's satisfaction level also improved from 60 to 80%. CONCLUSIONS: After this clinical service innovation, there was significant reduction in referrals of measles patients to another hospital and consequently there was an increase in the patient's satisfaction.

Temperament and character profiles are associated with depression outcome in psychiatric secondary care patients with harmful drinking.

BACKGROUND: Temperament and character profiles have been associated with depression outcome and alcohol abuse comorbidity in depressed patients. How harmful alcohol use modifies the effects of temperament and character on depression outcome is not well known. Knowledge of these associations could provide a method for enhancing more individualized treatment strategies for these patients. METHODS: We screened 242 depressed patients with at least moderate level of depressive symptoms. The Alcohol Use Disorders Identification Test (AUDIT) was used for identifying patients with marked alcohol use problems (AUP, AUDIT≥11). After 6 weeks of antidepressive treatment 173 patients were assessed using the Montgomery-Åsberg Depression Rating Scale (MADRS), and the Temperament and Character Inventory (TCI-R). Outcome of depression (MADRS scores across three follow-up points at 6 weeks, 6 months and 24 months) was predicted with AUP, gender, and AUP x Gender and AUP x Time interactions together with temperament and character dimension scores in a linear mixed effects model. RESULTS: Poorer outcome of depression (MADRS scores at 6 weeks, 6 months and 24 months) was predicted by AUP × Time interaction (p = 0.0002) together with low Reward Dependence (p = 0.003). Gender and all other temperament and character traits were non-significant predictors of the depression outcome in the mixed effects model. CONCLUSIONS: Possibly due to the modifying effect of alcohol use problems, high Reward Dependence was associated with better depression treatment outcome at 6 months. Harm Avoidance and Self-Directedness did not predict depression outcome when alcohol use problems were controlled.

Risk classification of patients referred to secondary care for low back pain.

BACKGROUND: Nonspecific low back pain is characterized by a wide range of possible triggering and conserving factors, and initial screening needs to scope widely with multilevel addressment of possible factors contributing to the pain experience. Screening tools for classification of patients have been developed to support clinicians. The primary aim of this study was to assess the criterion validity of STarT Back Screening Tool (STarT Back) against the more comprehensive Örebro Musculoskeletal Pain Questionnaire (ÖMPSQ), in a Norwegian sample of patients referred to secondary care for low back pain. Secondary aims were to assess risk classification of the patients, as indicated by both instruments, and to compare pain and work characteristics between patients in the different STarT Back risk categories. METHODS: An observational, cross-sectional survey among patients with low back pain referred to outpatient secondary care assessment at Trondheim University Hospital, Norway. Cohen's Kappa coefficient, Pearson's r and a Bland-Altman plot were used to assess criterion validity of STarT Back against ÖMPSQ. Furthermore, linear regression was used to estimate mean differences with 95% CI in pain and work related variables between the risk groups defined by the STarT Back tool. RESULTS: A total of 182 persons participated in the study. The Pearsons correlation coefficient for correspondence between scores on ÖMPSQ and STarT Back was 0.76. The Kappa value for classification agreement between the instruments was 0.35. Risk group classification according to STarT Back allocated 34.1% of the patients in the low risk group, 42.3% in the medium risk, and 23.6% in the high risk group. According to ÖMPSQ, 24.7% of the participants were allocated in the low risk group, 28.6% in the medium risk, and 46.7% in the high risk group. Patients classified with high risk according to Start Back showed a higher score on pain and work related characteristics as measured by ÖMPSQ. CONCLUSION: The correlation between score on the screening tools was good, while the classification agreement between the screening instruments was low. Screening for work factors may be important in patients referred to multidisciplinary management in secondary care.

Outcome of patients with dual diagnosis in secondary psychiatric care.

BACKGROUND: Dual diagnosis (DD) is a common co-morbidity of mental illness and substance use disorder (SUD) and patients with DD are prone to complications. Better knowledge on the outcome, mortality and management of patients with DD in usual secondary psychiatric care would help to inform improved treatment strategies in the future. AIMS: To explore the functional outcome and mortality of patients with DD receiving psychiatric treatment. To assess the recognition of substance use disorders (SUDs) in terms of diagnosis, and the associations of clinically diagnosed SUDs with treatment-related variables. METHODS: The sample of 330 patients was collected by screening all currently treated patients with the Alcohol Use Disorders Identification Test (AUDIT) and a question about other substances used. The inclusion criteria were AUDIT >7 and/or reported use of other substances during the preceding 12 months. The Global Assessment of Functioning scale was used to assess functional outcomes during a 2-year follow-up. Information concerning treatment and patient characteristics was collected retrospectively. RESULTS: Level of functioning remained stable among all study patients during follow-up. The mortality rate was not increased. Effective medication use was associated with improved functional outcomes. SUDs were underdiagnosed. A clinically diagnosed SUD seemed to have an impact on the regularity of appointments and the doses of prescribed medications. CONCLUSIONS: Given our results suggesting a stable level of functioning, patients with DD appear to be well managed within secondary psychiatric care. Attention should be paid to more precise diagnostics of SUDs and to effective use of medication.

Rising to the challenge of health care reform with entrepreneurial and intrapreneurial nursing initiatives.

Health reform worldwide is required due to the largely aging population, increase in chronic diseases, and rising costs. To meet these needs, nurses are being encouraged to practice to the full extent of their skills and take significant leadership roles in health policy, planning, and provision. This can involve entrepreneurial or intrapreneurial roles. Although nurses form the largest group of health professionals, they are frequently restricted in their scope of practice. Nurses can help to improve health services in a cost effective way, but to do so, they must be seen as equal partners in health service provision. This article provides a global perspective on evolving nursing roles for innovation in health care. A historical overview of entrepreneurship and intrapreneurship is offered. Included also is discussion of a social entrepreneurship approach for nursing, settings for nurse entre/intrapreneurship, and implications for research and practice.

[General Practice: continuously developing]. / Huisartsgeneeskunde: continu in ontwikkeling.

Over the past 10 years there have been significant developments in general practice regarding diagnostics, differentiation of competences of general practitioners, cooperation within primary care and with secondary care, task delegation and patient information provision. Less progress has been made in other areas: E-health applications are rarely used, and there is no clear guideline for an integrated policy in patients with multimorbidity. General practitioners also continue to suffer from excessive regulatory pressure, excessive protocols and standardization. In the coming decade, GPs will continue to work in accordance with the core values ​​of their profession: 'person-oriented', 'medical-generalist', 'continuous' and 'jointly'. Their function to provide guidance is becoming increasingly important. In addition, more diagnostics and treatment will take place at the interface between general practice and secondary care. Chronic care will focus more on the needs and wishes of the individual patient. GPs retain their important role in terminal palliative care and emergency care.

Poor predictive value of lower gastrointestinal alarm features in the diagnosis of colorectal cancer in 1981 patients in secondary care.

BACKGROUND: Clinicians are advised to refer patients with lower gastrointestinal (GI) alarm features for urgent colonoscopy to exclude colorectal cancer (CRC). However, the utility of alarm features is debated. AIM: To assess whether performance of alarm features is improved by using a symptom frequency threshold to trigger referral, or by combining them into composite variables, including minimum age thresholds, as recommended by the National Institute for Health and Care Excellence (NICE). METHODS: We collected data prospectively from 1981 consecutive adults with lower GI symptoms. Assessors were blinded to symptom status. The reference standard to define CRC was histopathological confirmation of adenocarcinoma in biopsy specimens from a malignant-looking colorectal lesion. Controls were patients without CRC. Sensitivity, specificity, positive predictive values (PPVs) and negative predictive values were calculated for individual alarm features, as well as combinations of these. RESULTS: In identifying 47 (2.4%) patients with CRC, individual alarm features had sensitivities ranging from 11.1% (family history of CRC) to 66.0% (loose stools), and specificities from 30.5% (loose stools) to 75.6% (family history of CRC). Using higher symptom frequency thresholds improved specificity, but to the detriment of sensitivity. NICE referral criteria also had higher specificities and lower sensitivity, with PPVs above 4.8%. More than 80% of those with CRC met at least one of the NICE referral criteria. CONCLUSIONS: Using higher symptom frequency thresholds for alarm features improved specificity, but sensitivity was low. NICE referral criteria had PPVs above 4.8%, but sensitivities ranged from 2.2% to 32.6%, meaning many cancers would be missed.

Drug utilization review of cephalosporins in a secondary care hospital in United Arab Emirates.

Background Cephalosporins are one of the most commonly used antibiotics in United Arab Emirates (UAE). Few studies have been carried out to evaluate the antibiotic utilization pattern in UAE in spite of the obvious increase in cephalosporins resistance during the past decade. Objective To assess the prescriptions pattern of cephalosporins among physicians at a secondary care hospital in Ras Al Khaimah, UAE. Method This observational prospective study was carried out during October 2013 to April 2014. The data of in patients were documented in the predesigned patient profile form and was analyzed for patient's, drug's and drug's therapy related parameters. Results The 3rd generation cephalosporins constituted 83.6 % of the prescriptions, with ceftriaxone being the most commonly used one (81.1 %). They were mainly prescribed for the treatment of the lower respiratory tract infections (60.2 %). Seven (3.5 %) different ADRs linked to cephalosporin use were observed ranging from oral thrush to clostridium difficile infection. A total of 1039 antimicrobial and nonantimicrobial medications were prescribed concomitantly with cephalosporins. Conclusion The 3rd generation cephalosporins were commonly prescribed by parenteral route. Thus, there is a strong need for rationalizing their use to preserve their efficacy and prevent the development of resistance in the region.

The Impact of Small Spinal Curves in Adolescents Who Have Not Presented to Secondary Care: A Population-Based Cohort Study.

STUDY DESIGN: A prospective, population-based, birth cohort study. OBJECTIVE: The aim of this study was to identify whether there is any hidden burden of disease associated with smaller spinal curves. SUMMARY OF BACKGROUND DATA: Adolescent idiopathic scoliosis is present in 3% to 5% of the general population. Large curves are associated with increased pain and reduced quality of life. However, no information is available on the impact of smaller curves, many of which do not reach secondary care. METHODS: The Avon Longitudinal Study of Parents and Children (ALSPAC) recruited over 14,000 pregnant women from the Bristol area of South-West England between 1991 and 1992 and has followed up their offspring regularly. At age 15, presence or absence of spinal curvature ≥6 degrees in the offspring was identified using the validated dual-energy X-ray absorptiometry Scoliosis Measure on 5299 participants. At age 18, a structured pain questionnaire was administered to 4083 participants. Logistic regression was used to investigate any association between presence of a spinal curve at age 15 and self-reported outcomes at age 18 years. RESULTS: Full data were available for 3184 participants. Two hundred two (6.3%) had a spinal curve ≥6 degrees and 125 (3.9%) had a curve ≥10 degrees (median curve size of 11 degrees). About 46.3% reported aches and pains that lasted for a day or longer in the previous month. About 16.3% reported back pain. Those with spinal curves were 42% more likely to report back pain than those without (odds ratio 1.42, 95% confidence interval 1.00-2.02, P = 0.047). Those with spinal curves had more days off school and were more likely to avoid activities that caused their pain. CONCLUSION: Our results highlight that small scoliotic curves may be less benign than previously thought. Teenagers with small curves may not present to secondary care, but are nonetheless reporting increased pain, more days off school, and avoidance of activities. These data suggest that we should reconsider current scoliosis screening and treatment practices. LEVEL OF EVIDENCE: 2.

The increasing secondary care burden of idiopathic pulmonary fibrosis: hospital admission trends in England from 1998 to 2010.

BACKGROUND: The lack of mandatory clinical registries for idiopathic pulmonary fibrosis (IPF) has meant a reliance on routine clinical data to provide trends in disease incidence. Death certificate and primary care data suggest that the incidence of IPF has increased in the United Kingdom at a rate of approximately 5% per year, but due to possible concerns about the diagnostic validity of these clinical datasets, it is helpful also to analyze data from secondary care. We used national secondary care data to determine trends in hospital admissions for IPF clinical syndrome (IPF-CS) in England between 1998 and 2010. METHODS: We obtained the annual number of hospital admissions for all National Health Service (NHS) hospital trusts in England for the International Classification of Diseases and Related Health Problems, 10th Revision codes J84.1 and J84.9 between 1998 and 2010. We calculated annual admission-rate ratios, adjusting for age and sex, using Poisson regression. We also investigated changes in age at admission and length of stay, and we estimated hospitalization costs. RESULTS: The number of hospital admissions from IPF-CS increased at an annual rate of approximately 5%, from 5,524 patients in 1998 to 9,525 patients in 2010, and was highest in men and the older population. Mean age at admission increased from 66 to 71 years, while length of stay decreased by 2.1 days during the same period. CONCLUSIONS: Hospital admissions for IPF-CS in England follow a similar trend to other data sources in the United Kingdom . This has resulted in escalating costs of inpatient care, which is a significant financial burden on health-care resources.

The UK National Health Service: delivering equitable treatment across the spectrum of coronary disease.

BACKGROUND: Social gradients in cardiovascular mortality across the United Kingdom may reflect differences in incidence, disease severity, or treatment. It is unknown whether a universal healthcare system delivers equitable lifesaving medical therapy for coronary heart disease. We therefore examined secular trends in the use of key medical therapies stratified by socioeconomic circumstances across a broad spectrum of coronary disease presentations, including acute coronary syndromes, secondary prevention, and clinical angina. METHODS AND RESULTS: This was a cross-sectional observational analysis of nationally representative primary and secondary care data from the United Kingdom. Data on treatments for all myocardial infarction patients in 2003 and 2007 were derived from the Myocardial Ischemia National Audit Project (n=51 755). Data on treatments for patients with chronic angina (n=33 211) or requiring secondary prevention (n=32 976) in 1999 and 2007 were extracted from the General Practice Research Database. Socioeconomic circumstances were defined using a weighted composite of 7 area-level deprivation domains. Treatment estimates were age-standardized. Use of all therapies increased in all patient groups, both men and women. Improvements were most marked in primary care, where use of ß-blockers, statins, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for secondary prevention and treatment of angina doubled, from ≈30% to >60%. Small age gradients persisted for some therapies. No consistent socioeconomic gradients or sex differences were observed for myocardial infarction and postrevascularization (hard diagnoses). However, some sex inequality was apparent in the treatment of younger women with angina. CONCLUSIONS: Cardiovascular treatment is generally equitable and independent of socioeconomic circumstances. Future strategies should aim to further increase overall treatment levels and to eradicate remaining age and sex inequalities.

Não comparecimentos às primeiras consultas odontológicas na atenção secundária em um município mineiro de grande porte / No-shows to the first scheduled dental appointments for secondary care in a large Minas Gerais city

O não comparecimento de usuários a consultas agendadas, especificamente aquele relativo à atenção secundária odontológica em Belo Horizonte, não é problema recente, representando impactos à saúde, prejuízos à resolutividade e integralidade do cuidado, além de custos desnecessários ao sistema. O presente estudo, por meio do método quantitativo, visou à identificação e análise de possíveis fatores associados aos não comparecimentos, em 2011, às primeiras consultas odontológicas agendadas de usuários residentes em Belo Horizonte, pertencentes a ambos os sexos, com idade igual ou superior a 18 anos referenciados, a partir da atenção primária, para as especialidades odontológicas cirurgia, endodontia, periodontia e disfunção têmporo-mandibular, no Centro de Especialidades Odontológicas (CEO) Centro-Sul. Foi utilizada pesquisa em base de dados secundários do Sistema de Regulação da Secretaria Municipal de Saúde da Prefeitura de Belo Horizonte(SMSA/PBH). A variável dependente foi o "não comparecimento" à primeira consulta agendada e as variáveis independentes analisadas foram: idade, tempo na fila de espera, sexo, distrito sanitário de origem e especialidade para a qual o usuário foi referenciado. Foram utilizados os testes de Mann-Whitney e qui-quadrado de Pearson para análise bivariada e regressão de Poisson com variância robusta para análise multivariada. Os testes foram conduzidos com um nível de significância de 5% e intervalo de confiança de 95%. Entre as 6.428 primeiras consultas odontológicas agendadas para 2011, nas quatro especialidades selecionadas para análise, 32,9% não foram realizadas em função da ausência do usuário...

Análise dos serviços de atenção secundária na especialidade de endodontia de municípios de Minas Gerais: percepções de usuários e endodontistas / Analysis of the secondary care services in endodontics of Minas Gerais cities: patients and progessional perceptions

O processo de avaliação dos serviços é uma ferramenta importante da gestão, na evolução e construção do SUS, norteando-lhe o planejamento, auxiliando-o na tomada de decisões. Na Endodontia, a introdução dos instrumentos rotatórios de níquel-titãnio facilitou o preparo e a limpeza do sistema de canais radiculares, em menor tempo e com maior eficiência clínica. Possibilitou melhor qualidade nas obturações dos canais radiculares, e menor fadiga tanto para os pacientes quanto para os profissionais, permitindo-lhes assistir a um maior número de indivíduos com alta qualidade técnica...