Evaluation of an intervention in general practices to strengthen social activities in older patients - A qualitative study of patients' experiences in the project HoPES3.

OBJECTIVE: In the research project HoPES3, the effectiveness of a multifaceted intervention, where one of the aims was to encourage social activities among older patients, was investigated in a cluster-randomised controlled trial. Patients were offered a conversation about their spirituality (spiritual history) which also included questions about their social relationships. The aim of this study was to examine patients' experiences regarding the acceptability, feasibility, conversational content and perceived benefits and harms of the interventions focusing on social relationships and activities. METHOD: Semi-structured interviews with 29 patients of the intervention group aged 70 years or older. RESULTS: Loneliness in old age is the result of a long history with underlying complex reasons. Activities proposed by the practice team were rarely carried out, but if they were, patients reported strong benefits. Patients reported their GPs' interest in their lives had resulted in a more trusting doctor-patient relationship. Almost all patients recommended to implement the intervention in general practices. CONCLUSION AND PRACTICE IMPLICATIONS: When raising the topic of loneliness, it is crucial to give patients the opportunity to explain the biographical developments which led to their situation. Therefore, embedding the conversation into a broader context such as a spiritual history might be helpful.

The role of non-dietetic healthcare professionals in managing interventions among adults at risk of malnutrition: A systematic review.

BACKGROUND: Malnutrition is estimated to affect over three million people in the UK resulting in serious consequences on both the individuals' health and healthcare system. While dietitians are uniquely qualified to provide nutritional interventions, they have one of the lowest workforce numbers in the NHS making it difficult to tackle the malnutrition burden alone. Thus, innovative ways of working are needed. Non-dietetic health care professionals are often involved in the identification, assessment and treatment of malnutrition and research has shown benefits of their involvement in identification and management of nutritional issues, however their role in delivering nutritional interventions has not yet been evaluated. The aim of this systematic review is to collate evidence on the potential roles and effectiveness of non-dietetic healthcare professionals in providing nutritional interventions and their impact on patient-centred outcomes in malnourished or at-risk individuals. METHODS: Three electronic databases were searched on 10th October 2019. Titles and abstracts were initially screened, followed by full texts, against inclusion criteria and included/excluded studies by two authors independently. Data were extracted and tabulated where possible and grouped according to type of intervention and outcomes. Risk of bias and quality of evidence was assessed using the GRADE approach. Data were combined in the form of a narrative synthesis. RESULTS: Eighteen eligible studies were included; five involved feeding assistance, 10 involved implementing individualised nutrition monitoring or care plans and three were multi-factorial interventions. Interventions took place in a range of settings including hospital and long term care facilities. Very low and low quality evidence suggests that non-dietetic HCP interventions may improve weight, percent of patients reaching estimated energy requirements, quality of life, falls and frailty rate and patient satisfaction. Very low quality evidence suggests that non-dietetic HCP interventions may not improve mid-arm circumference, energy or protein intake, activities of daily living, handgrip strength or length of hospital stay. Low quality evidence suggests that non-dietetic HCP interventions have no effect on mortality. CONCLUSIONS: A lack of good quality evidence on the effectiveness of non-dietetic HCP delivered interventions on the management of malnutrition in adults makes it difficult to draw conclusions. However, this review has highlighted the types of interventions and potential roles of non-dietetic HCPs, providing a groundwork for further high-quality research such as feasibility studies in this area, for the effective management of malnutrition within clinical and community practice.

Employment of Telemedicine in Nursing Homes: Clinical Requirement Analysis, System Development and First Test Results.

PURPOSE: Demographic change and lack of specialized workforces are challenging. Likewise, home visits by general practitioners (GPs) become rarer. If a nursing home resident develops acute symptoms, nurses are often inclined to call the rescue service. Besides patient-related consequences, this might lead to unnecessary hospitalization and far-reaching health economic costs. Due to legal restrictions of remote treatment in Germany, which were recently loosened, telemedicine is still in the early stages. The aim of this study was to employ a holistic telemedical system for nursing homes which facilitates the connection to a GP and thus avoids unnecessary hospitalizations in the case of ambulatory-sensitive illnesses. MATERIALS AND METHODS: After an inter-professional requirement analysis, the iterative development was started. In addition to an audio-video connection, several point of care measurements were integrated. Finally, first field tests were performed in a nursing home in a rural area in Germany. RESULTS: One nursing home was equipped with telemedical system based on the results of the requirement analysis and tele-medically connected to a GP. Over a period of seven months, 56 routine and emergency teleconsultations took place. Only one of those required a hospital admission. In addition to video telephony, electrocardiography and assessment of vitals such as pulse, blood pressure, oxygen saturation and auscultation of heart and lungs were applied frequently. CONCLUSION: A telemedical system including integrated medical devices was successfully developed and has turned out to be helpful and even necessary for careful and reliable decision-making by the GP. First test results show high acceptance for elderly care. Involved patients, nurses, and the GP itemize various specific benefits, including economic, personal, and altruistic issues. Another issue that the current COVID-19 crisis brought to light is lowering the risk of contagion; GPs can replace their home visits by using telepresence combined with point of care measures.

Beyond ventilatory support: challenges in general practice and in the treatment of critically Ill children and adolescents with SARS-CoV-2 infection.

Severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2 infection) is a new challenge for all countries, and children are predisposed to acquire this disease. Some studies have demonstrated more severe diseases in adults, but critically ill pediatric patients have been described in all ages. Pulmonary involvement is the major feature, and ventilatory support is common in critical cases. Nevertheless, other very important therapeutic approaches must be considered. In this article, we reviewed extensively all recent medical literature to point out the main clinical attitudes to support these pediatric patients during their period in respiratory support. Radiologic findings, fluid therapy, hemodynamic support, use of inotropic/vasopressors, nutritional therapy, antiviral therapy, corticosteroids, antithrombotic therapy, and immunoglobulins are analyzed to guide all professionals during hospitalization. We emphasize the importance of a multi-professional approach for adequate recovery.

Factors affecting the embedding of integrated primary-secondary care into a health district.

With the aging population, the tide of chronic disease is rising with attendant increases in health service need. Integrated care and patient-centred approaches, which established partnerships between a regional Hospital and health service (HHS), the local primary health network and local general practitioners (GPs), were identified as exemplars of an approach needed to support growing community health needs. This paper summarises the findings from a process evaluation of four GP-specialist care integration programs with the aim of identifying recommendations for embedding integrated GP-specialist care into routine practice within the HHS. The process evaluation of the integration programs drew on input from a multidisciplinary expert advisory group and data collected through face-to-face semi-structured interviews with key stakeholders, as well as surveys of participating GPs and patients. Overarching findings were identified and grouped under six themes: interdisciplinary teamwork; communication and information exchange; the use of shared care guidelines or pathways; training and education; access and accessibility; and funding. Within each theme, key challenges and enablers emerged. The findings of this study highlight benefits and challenges associated with the establishment of integrated care between primary and secondary care providers, leading to the development of key recommendations for routine integration.

[How to improve social and professional reinsertion of patients with neurodiabilities ? Practical indications for the general practitioner]. / Comment faciliter la réinsertion socioprofessionnelle du patient neurolésé ? Outils pour le praticien.

One part of the population of neurolesioned patients is the transition of young patients with neurodisabilities to adult life. To guarantee favourable social and professional reinsertion is a major challenge, requiring inter-professional care. For this reason, in 2006 the CHUV, Lausanne created a transition-consultation framework with neuro-paediatricians and adult neurologists specialised in neuro-rehabilitation linked to a Swiss pilot social and professional reinsertion project collaborating with the invalidity insurance. As a model of the follow up of neurolesioned patients, this article reports the results of the reinsertion project that aims to bring awareness to the general practitioner of an inter-disciplinary care method adaptable to individuals. The holistic service saves time and improves the rate of successful reinsertion of young adults into social and professional life.

Les jeunes en transition de l'enfance à l'âge adulte présentant une maladie neurodéveloppementale sont une population spécialement vulnérable. Le suivi de leurs problèmes de santé et leur insertion socioprofessionnelle représentent un véritable défi. Au CHUV, à Lausanne, une consultation de transition entre les neurorééducateurs pédiatriques et adultes a été créée en 2006 ainsi qu'un projet pilote suisse de réinsertion socioprofessionnelle en collaboration avec l'Office de l'assurance invalidité pour le canton de Vaud. Le résultat de ce projet pilote, qui peut être utilisé comme modèle pour tous les patients neurolésés, est rapporté ici avec comme objectif d'informer le médecin traitant et de lui permettre d'utiliser les outils de cette prestation holistique afin d'optimiser la durée et la qualité de la réinsertion.

Beyond ventilatory support: challenges in general practice and in the treatment of critically Ill children and adolescents with SARS-CoV-2 infection

SUMMARY Severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2 infection) is a new challenge for all countries, and children are predisposed to acquire this disease. Some studies have demonstrated more severe diseases in adults, but critically ill pediatric patients have been described in all ages. Pulmonary involvement is the major feature, and ventilatory support is common in critical cases. Nevertheless, other very important therapeutic approaches must be considered. In this article, we reviewed extensively all recent medical literature to point out the main clinical attitudes to support these pediatric patients during their period in respiratory support. Radiologic findings, fluid therapy, hemodynamic support, use of inotropic/vasopressors, nutritional therapy, antiviral therapy, corticosteroids, antithrombotic therapy, and immunoglobulins are analyzed to guide all professionals during hospitalization. We emphasize the importance of a multi-professional approach for adequate recovery.

RESUMO A síndrome respiratória aguda grave (SRAG) pelo novo coronavirus (SARS-CoV-2) é um novo desafio para todos os países e crianças estão predispostas a adquirir a doença. Alguns estudos demonstraram quadros mais graves em adultos, mas crianças criticamente doentes foram descritas em todas as idades. O envolvimento pulmonar é a principal característica e a necessidade de suporte ventilatório é comum nos casos mais graves. Entretanto, outras abordagens terapêuticas importantes devem ser consideradas. Nesse artigo revisamos extensamente a literature médica até o momento a fim de citar os principais recursos terapêuticos para o manejo dos pacientes pediátricos durante o período de suporte ventilatório. Achados radiológicos, terapia fluídica, terapia antiviral, o uso de corticosteroides, terapia antitrombótica e o uso de imunoglobulinas foram analisados a fim de guiar os profissionais durante o período de hospitalização desses pacientes. Nós reforçamos a importância de uma abordagem multiprofissional para recuperação adequada.

Manual therapy as a prophylactic treatment for migraine: design of a randomized controlled trial.

BACKGROUND: People with migraine often experience disability with serious consequences for their social life and work productivity. The pharmacological prophylactic management of migraine is effective in reducing migraine attacks. However, many people are reluctant to use daily prophylactic medication, leading to a demand for non-pharmacological treatment options. We present the design for and discuss the feasibility of a pragmatic, randomized controlled trial on the effectiveness of a multimodal manual therapy (MT) treatment compared to usual care by the general practitioner (GP) for the prophylactic treatment of migraine. METHODS: Eligible participants will be recruited in primary care using the International Classification of Headache Disorders III criteria for migraine of the International Headache Society. Participants will be randomized to either multimodal MT treatment or usual care provided by the GP. GPs will be asked to treat the usual care group according to the Dutch GP guideline for headache. The multimodal MT intervention will include manual pressure techniques, neck muscle-strength exercises and mobilization of the cervical and thoracic spine. The trial will consist of a 12-week treatment period and follow-up measurements at 12, 26 and 52 weeks. The primary outcome measure is the number of migraine days per 4 weeks, assessed with a headache diary. Secondary outcome measures are the number of migraine attacks, medication use, disability due to headache, headache intensity, number of participants reporting a 50% migraine reduction, measurement of cervical pressure pain thresholds, presence of allodynia, endurance of cervical flexor muscles, days of absence of work and global perceived effect. DISCUSSION: The results of the trial will show whether a multimodal MT intervention is an effective non-pharmacological treatment option for people with migraine. TRIAL REGISTRATION: Dutch Trial Register, NL7504. Registered on 7 February 2019.

Design of the ZWOT-CASE study: an observational study on the effectiveness of an integrated programme for cardiovascular risk management compared to usual care in general practice.

BACKGROUND: Cardiovascular diseases (CVD) contribute considerably to mortality and morbidity. Prevention of CVD by lifestyle change and medication is important and needs full attention. In the Netherlands an integrated programme for cardiovascular risk management (CVRM), based on the Chronic Care Model (CCM), has been introduced in primary care in many regions in recent years, but its effects are unknown. In the ZWOT-CASE study we will assess the effect of integrated care for CVRM in the region of Zwolle on two major cardiovascular risk factors: systolic blood pressure (SBP) and low-density lipoprotein cholesterol (LDL-cholesterol) in patients with or at high risk of CVD. METHODS: This study is a pragmatic observational study comparing integrated care for CVRM with usual care among patients aged 40-80 years with CVD (n = 370) or with a high CVD risk (n = 370) within 26 general practices. After 1 yr follow-up, primary outcomes (SBP and LDL-cholesterol level) are measured. Secondary outcomes include lifestyle habits (smoking, dietary habits, alcohol use, physical activity), risk factor awareness, 10-year risk of cardiovascular morbidity or mortality, health care consumption, patient satisfaction and quality of life. CONCLUSION: The ZWOT-CASE study will provide insight in the effects of integrated care for CVRM in general practice in patients with CVD or at high CVD risk. TRIAL REGISTRATION: The ZWOlle Transmural Integrated Care for CArdiovaScular Risk Management Study; ClinicalTrials.gov ; Identifier: NCT03428061; date of registration: 09-02-2018; This study has been retrospectively registered.

[Use of placebo in French hospitals: data from polyvalent medicine units]. / Le placebo à l'hôpital - Regard sur son utilisation dans les services de médecine polyvalente.

A placebo drug is defined as a treatment without any specific pharmacological efficacy, that works when the patient thinks to receive an active treatment, through a psychological and physiological mechanism. This study aimed to evaluate the use of placebo in French hospitals, in Polyvalent Medicine units. A questionnaire comprising 15 items was sent to 372 units. The analysis of 153 responses was conducted from dynamic crosstabs in Excel and using the R software available online. The survey confirmed that the use of placebos in hospital is frequent, with nearly 2/3 of professionals answering the questionnaire declared to use it. The oral capsule is the most commonly used form. Placebo is mainly administered at night, in case of pain, insomnia or anxiety, to so-called "difficult" patients. Placebo is not always given after medical prescription. In most cases, patients are not informed that they receive a placebo. The majority of professionals believed in the placebo effect but considered to be insufficiently informed and trained in the use of placebo in current practice. Although the placebo effect is now demonstrated, ethical and legal considerations recommend placebo treatment only on medical prescription, with the prior information of the patient. The placebo could be used as complementary therapy to conventional treatment in the cases of this therapeutic effectiveness has been demonstrated. Professionals should be trained in the use of placebo in order to avoid nocebo effect and potentiate beneficial effects of placebo.

TITLE: Le placebo à l'hôpital - Regard sur son utilisation dans les services de médecine polyvalente. ABSTRACT: Un placebo est défini comme un traitement sans efficacité pharmacologique propre qui agit, lorsque le patient pense recevoir un traitement actif, par des mécanismes psychologiques et physiologiques. Notre étude avait pour but d'évaluer l'utilisation du placebo dans les unités de médecine polyvalente des hôpitaux français. Pour cela, un questionnaire comprenant 15 items a été transmis à plusieurs unités. L'analyse des réponses reçues confirme que l'utilisation de placebos à l'hôpital est fréquente, près des deux tiers des professionnels ayant répondu déclarent en faire usage. L'administration du placebo en gélule par voie orale est la forme la plus couramment utilisée. À l'hôpital, il est administré principalement la nuit, le plus souvent sans prescription médicale, en cas de douleur, d'insomnie ou d'anxiété, à des patients dits « difficiles ¼ (solliciteurs d'attention et de soin). Dans la plupart des cas, les patients ne sont pas informés qu'il s'agit d'un placebo. La majorité des professionnels « croit ¼ en l'effet placebo, mais se considèrent cependant insuffisamment informés et formés à son utilisation. Fréquemment utilisé à l'hôpital, son efficacité thérapeutique étant largement admise, des considérations éthiques et juridiques imposent de recommander que sa nature soit précisée au patient lors de sa prescription (au même titre que les autres préparations hospitalières). On parlera alors de « placebo ouvert ¼, c'est-à-dire que des explications sur les effets et les mécanismes d'action du placebo seront données au patient. Des études récentes montrent que dire au patient qu'il reçoit un placebo ouvert n'affecte en rien son effet.

General practitioners' perspectives on the prevention of cardiovascular disease: systematic review and thematic synthesis of qualitative studies.

OBJECTIVE: Cardiovascular disease (CVD) is a leading cause of morbidity and mortality globally, and prevention of CVD is a public health priority. This paper aims to describe the perspectives of general practitioners (GPs) on the prevention of CVD across different contexts. DESIGN: Systematic review and thematic synthesis of qualitative studies using the Enhancing Transparency of Reporting the Synthesis of Qualitative research (ENTREQ) framework. DATA SOURCES: MEDLINE, Embase, PsycINFO and CINAHL from database inception to April 2018. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included qualitative studies on the perspectives of GPs on CVD prevention. DATA EXTRACTION AND SYNTHESIS: We used HyperRESEARCH to code the primary papers and identified themes. RESULTS: We selected 34 studies involving 1223 participants across nine countries. We identified six themes: defining own primary role (duty to prescribe medication, refraining from risking patients' lives, mediating between patients and specialists, delegating responsibility to patients, providing holistic care); trusting external expertise (depending on credible evidence and opinion, entrusting care to other health professionals, integrating into patient context); motivating behavioural change for prevention (highlighting tangible improvements, negotiating patient acceptance, enabling autonomy and empowerment, harnessing the power of fear, disappointment with futility of advice); recognising and accepting patient capacities (ascertaining patient's drive for lifestyle change, conceding to ingrained habits, prioritising urgent comorbidities, tailoring to patient environment and literacy); avoiding overmedicalisation (averting long-term dependence on medications, preventing a false sense of security, minimising stress of sickness) and minimising economic burdens (avoiding unjustified costs to patients, delivering practice within budget, alleviating healthcare expenses). CONCLUSIONS: GPs sought to empower patients to prevent CVD, but consideration of patients' individual factors was challenging. Community-based strategies for assessing CVD risk involving other health professionals, and decision aids that address the individuality of the patient's health and environment, may support GPs in their decisions regarding CVD prevention.

Screening for familial hypercholesterolaemia in primary care: Time for general practice to play its part.

Fifty per cent of first-degree relatives of index cases with familial hypercholesterolemia (FH) inherit the disorder. Despite cascade screening being the most cost-effective method for detecting new cases, only a minority of individuals with FH are currently identified. Primary care is a key target area to increase identification of new index cases and initiate cascade screening, thereby finding close relatives of all probands. Increasing public and health professional awareness about FH is essential. In the United Kingdom and in Australia, most of the population are reviewed by a General Practitioner (GP) at least once over a three-year period, offering opportunities to check for FH as part of routine clinical consultations. Such opportunistic approaches can be supplemented by systematically searching electronic health records with information technology tools that identify high risk patients. GPs can help investigate and implement results of this data retrieval. Current evidence suggests that early detection of FH and cascade testing meet most of the criteria for a worthwhile screening program. Among heterozygous patients the long latent period before the expected onset of coronary artery disease provides an opportunity for initiating effective drug and lifestyle changes. The greatest challenge for primary care is to implement an efficacious model of care that incorporates sustainable identification and management pathways.

Trauma-informed care in general practice: Findings from a women's health centre evaluation.

BACKGROUND AND OBJECTIVES: Trauma and adversity have serious health consequences, particularly when experienced in early life. These health consequences can be significantly lessened if young people access appropriate care when needed. In 2004, the Blue Mountains Women's Health and Resource Centre created a Young Women's Clinic (YWC) that began providing drop-in appointments for women aged 12-25 years with a general practitioner, nurse or counsellor, as well as a group art program. METHOD: A qualitative evaluation of services provided by the YWC was conducted, drawing on 13 years of client and staff experiences. The evaluation framework was drawn from the recommendations of the NSW Centre for Advancement of Adolescent Health, the Australian Women's Health Network and the World Health Organization report on People-centred and integrated health services. RESULTS: The following principles of trauma-informed care were identified in the study: recognising the impact of trauma on consultations; tailoring consultation length to client needs; providing trauma therapy as well as physical healthcare; offering long-term, safe relationships with staff; trauma-sensitive gynaecological care; and the importance of self-care for health practitioners. DISCUSSION: Our findings demonstrate the importance of holistic general practice services in preventing and managing the long-term health consequences of adversity and trauma.

Obstetrical provider knowledge and attitudes towards cell-free DNA screening: results of a cross-sectional national survey.

BACKGROUND: Cell-free DNA (cfDNA) screening has recently acquired tremendous attention, promising patients and healthcare providers a more accurate prenatal screen for aneuploidy than other current screening modalities. It is unclear how much knowledge regarding cfDNA screening obstetrical providers possess which has important implications for the quality and content of the informed consent patients receive. METHODS: A survey was designed to assess obstetrical provider knowledge and attitudes towards cfDNA screening and distributed online through the Society of Obstetricians & Gynecologists of Canada (SOGC). Chi-squared tests were used to detect differences in knowledge and attitudes between groups. RESULTS: 207 respondents completed the survey, composed of 60.6% Obstetricians/Gynecologists (OB/GYN), 15.4% Maternal Fetal Medicine (MFM) specialists, 16.5% General Practitioners (GP), and 7.5% Midwives (MW). MFM demonstrated a significant trend of being most knowledgeable about cfDNA screening followed by OB/GYN, GP, and lastly MW in almost all aspects of cfDNA screening. All groups demonstrated an overall positive attitude towards cfDNA screening; however, OB/GYN and MFM demonstrated a significantly more positive attitude than GP and MW. Despite not yet being a diagnostic test, 19.4% of GP would offer termination of pregnancy immediately following a positive cfDNA screen result compared to none of the MFM and only few OB/GYN or MW. CONCLUSIONS: We have demonstrated that different types of obstetrical providers possess varying amounts of knowledge regarding cfDNA screening with MFM currently having greater knowledge to all other groups. All obstetrical providers must have adequate prenatal screening understanding so that we can embrace the benefits of this novel and promising technology while protecting the integrity of the informed consent process.

Systematic review of the effectiveness, barriers and facilitators to general practitioner engagement with specialist secondary services in integrated palliative care.

The general practitioner (GP) has a critical role in an integrated model of palliative care as they often know the patient and carer well, are experts in generalist care and have knowledge of health and social services in the community. Specialist palliative services have insufficient capacity to meet demand and those with non-cancer terminal conditions and those from rural and remote areas are underserved. Research has focused on improving access to palliative care by engaging the GP with specialist secondary services in integrated palliative care. OBJECTIVES: (1) Evaluate the effectiveness of interventions designed to engage GPs and specialist secondary services in integrated palliative care; and (2) identify the personal, system and structural barriers and facilitators to integrated palliative care. METHOD: MEDLINE, EMBASE and CINAHL were searched. Any study of a service that engaged the GP with specialist secondary services in the provision of palliative care was included. GP engagement was defined as any organised cooperation between the GP and specialist secondary services in the care of the patient including shared consultations, case conferences that involved at least both the GP and the specialist clinician and/or other secondary services, and/or any formal shared care arrangements between the GP and specialist services. The specialist secondary service is either a specialist palliative service or a service providing specialist care to a palliative population. A narrative framework was used to describe the findings. RESULTS: 17 studies were included. There is some evidence that integrated palliative care can reduce hospitalisations and maintain functional status. There are substantial barriers to providing integrated care. Principles and facilitators of the provision of integrated palliative care are discussed. CONCLUSIONS: This is an emerging field and further research is required assessing the effectiveness of different models of integrated palliative care.

Private and institutionalised patients' use of homeopathy in the early nineteenth century.

Medicine underwent a major crisis in the 18th century and several approaches, including homeopathy, were formulated to fill the void left by the fall of traditional Galenic medicine. While most of the literature deals with the reasons doctors had to shift to homeopathy, the patients' views became the focus of increasing scholarly attention along the past 20 years. In this article I present and discuss the current knowledge about the socio-demographic characteristics and medical complaints of patients who sought homeopathic care in the early 19th century in both private and institutional settings. The results show that not only patients from the higher and more educated classes sought homeopathic care, but a considerable number of individuals from the middle and lower strata did so too, even though they also had access to conventional hospitals. As to the clinical complaints, the reasons to seek homeopathic care were the typical ones for any general practice or hospital in the period considered.