Exercise Compared to Mindfulness for Physical and Mental Wellbeing in Medical Students.

Aim Physical Activity (PA) and Mindfulness-Based Stress Reduction (MBSR) both have positive effects on medical student well-being. The 'MED-WELL' programme is a curricular intervention that combines PA and education on exercise as medicine. This trial evaluates whether there is a mean difference in outcomes of participants of an exercise intervention, the 'MED-WELL' programme, versus a control group which engages in a MBSR programme. Methods All second-year medical students were voluntarily allocated into the intervention or control group. Data on overall health and well-being, sleep quality, loneliness, current level of PA, and confidence in prescribing exercise as medicine was analysed from both groups at baseline and after eight weeks. Results Within groups the intervention and control groups showed statistically significant improvements in overall well-being (p=0.010, p=0.005 respectively) and in sleep quality (p<0.001, p=0.007 respectively). The intervention group had statistically significant improvements in levels of PA (p=0.003) and confidence in prescribing exercise (p<0.001). However, there were no statistically significant differences in changes in outcome measures between groups. Conclusion This study has shown that participants in an exercise intervention, the 'MED-WELL' programme, had similar improvements in overall wellbeing and sleep quality to those in a control group who participated in a MBSR programme of the same duration.

Short- and long-term effects of gestational diabetes mellitus on healthcare cost: a cross-sectional comparative study in the ATLANTIC DIP cohort.

AIMS: This paper examines the association between gestational diabetes mellitus and costs of care during pregnancy and 2-5 years post pregnancy. METHODS: Healthcare utilization during pregnancy was measured for a sample of 658 women drawn from the Atlantic Diabetes in Pregnancy (ATLANTIC DIP) network. Healthcare utilization 2-5 years post pregnancy was assessed for a subsample of 348 women via a postal questionnaire. A vector of unit costs was applied to healthcare activity to calculate the costs of care at both time points. Differences in cost for women with gestational diabetes mellitus compared with those with normal glucose tolerance during the pregnancy were examined using univariate and multivariate regression analyses. RESULTS: Gestational diabetes mellitus was independently associated with an additional €817.60 during pregnancy (€1192.1 in the gestational diabetes mellitus group, €511.6 in the normal glucose tolerance group), in the form of additional delivery and neonatal care costs, and an additional €680.50 in annual healthcare costs 2-5 years after the index pregnancy (€6252.4 in the gestational diabetes mellitus group, €5434.8 in the normal glucose tolerance group). CONCLUSIONS: These results suggest that gestational diabetes mellitus is associated with increased costs of care during and post pregnancy. They provide indication of the associated cost that can be avoided or reduced by the screening, prevention and management of gestational diabetes mellitus in pregnancy. These estimates are useful for further studies that examine the cost and cost-effectiveness of such programmes.

Towards an integrated blood pressure self-monitoring solution for stroke/TIA in Ireland: a mixed methods feasibility study for the TASMIN5S IRL randomised controlled trial.

BACKGROUND: Optimising blood pressure (BP) control is one of the most important modifiable risk factors in preventing subsequent stroke where the risk increases by one-third for every 10 mmHg rise in systolic BP. This study evaluated the feasibility and potential effectiveness of blood pressure self-monitoring with planned medication titration, to inform a definitive trial of the intervention, in patients with a previous stroke or transient ischaemic attack (TIA). METHODS: Patients with a history of stroke/TIA and sub-optimal BP control were invited to take part in a mixed methods feasibility study for a randomised controlled trial. Those meeting the inclusion criteria with systolic BP >130 mmHg were randomised to a self-monitoring intervention group or usual care group. The intervention involved self-monitoring BP twice a day for 3 days within a 7-day period, every month, following text message reminders. Treatment escalation, based on a pre-agreed plan by the general practitioner (GP) and patient, was initiated according to the results of these readings. Semi-structured interviews were carried out with patients and clinicians and analysed thematically. RESULTS: Of those identified, 47% (32/68) attended for assessment. Of those assessed, 15 were eligible for recruitment and were consented and randomised to the intervention or control group on a 2:1 basis. Of those randomised, 93% (14/15) completed the study and there were no adverse events. Systolic BP was lower in the intervention group at 3 months. Participants found the intervention acceptable and easy to use. GPs found it easy to incorporate into their practice activity without increasing workload. CONCLUSIONS: TASMIN5S, an integrated blood pressure self-monitoring intervention in patients with a previous stroke/TIA, is feasible and safe to deliver in primary care. A pre-agreed three-step medication titration plan was easily implemented, increased patient involvement in their care, and had no adverse effects. This feasibility study provides important information to inform a definitive trial to determine the potential effectiveness of the intervention in patients post-stroke or TIA. TRIAL REGISTRATION: ISRCTN57946500 . Registered on 12/08/2019.

Chronic kidney disease in general practice: prevalence, diagnosis, and standards of care.

There is little prevalence data for chronic kidney disease (CKD) in Ireland and it has been suggested that rates of diagnosis of CKD in primary care are low. The aim of this cross sectional study was to examine the prevalence, diagnosis and standards of care for CKD. All patient records in three general practices in the West of Ireland were reviewed. In 2602 patients > 50 years in the community, 435 (16.7%) had chronic kidney disease defined as eGFR <60 ml/min/1.73 m2. Of these 435 individuals, only 58 (13.3%) had a diagnosis of CKD documented in their patient record. Among all patients with an eGFR <60 ml/min/1.73 m2, those with a documented diagnosis of CKD were significantly more likely to be prescribed an ACE/ARB and a lipid-lowering agent and were more likely to have had an ACR/PCR checked in the previous twelve months. Blood pressure was being appropriately monitored in the majority of patients but irrespective of eGFR level or a documented diagnosis of CKD, less than a fifth of patients had achieved a target of <130/80 mmHg. CKD is common in primary care but remains largely undiagnosed and blood pressure control remains suboptimal. A key step in improving care appears to be documenting the diagnosis which in turn appears to lead to improved standards of care and risk factor management.

Effect of rurality on patients' satisfaction with out of hours care provided by a family doctor cooperative.

INTRODUCTION: Reacting to demand and supply pressures, European healthcare systems are undergoing significant structural changes to the organisation and delivery of out of hours care. Such pressures are of particular concern to rural practice. Although patient satisfaction with out of hours care has been extensively studied, the effect of rurality on satisfaction levels has not, to our knowledge, been previously examined. OBJECTIVE: To investigate whether rurality has an influence on patient satisfaction with out of hours care provided by a family doctor co-operative. METHODS: All patients contacting the service over a designated 24-day period were forwarded a postal questionnaire. Patients' satisfaction was measured using a version of the McKinley questionnaire, and rurality, by subjective patient assessment, distance from treatment centre or previous rota cover. RESULTS: The response rate was 55% (531/966). Overall satisfaction levels were high with 88% of patients rating the service as either good or excellent. 47.8% of respondents perceived themselves as living in a town, 14.6% as living in a village, and 37.6% as living in the countryside. Perceived rurality, distance from treatment centre or previous rota cover did not significantly affect satisfaction levels. CONCLUSIONS: Family doctor co-operatives have significantly altered the way out of hours care is delivered. Patients from rural areas are equally satisfied with the provision of out of hours care by co-operatives, as urban patients. Extension of co-operatives to rural areas need not be constrained by concerns regarding decreased patient satisfaction.

A prospective study of risk factors for foot ulceration: the West of Ireland Diabetes Foot Study.

BACKGROUND: This is the first study to examine risk factors for diabetic foot ulceration in Irish general practice. AIM: To determine the prevalence of established risk factors for foot ulceration in a community-based cohort, and to explore the potential for estimated glomerular filtration rate (eGFR) to act as a novel risk factor. DESIGN: A prospective observational study. METHODS: Patients with diabetes attending 12 (of 17) invited general practices were invited for foot screening. Validated clinical tests were carried out at baseline to assess for vascular and sensory impairment and foot deformity. Ulcer incidence was ascertained by patient self-report and medical record. Patients were re-assessed 18 months later. RESULTS: Of 828 invitees, 563 (68%) attended screening. On examination 23-25% had sensory dysfunction and 18-39% had evidence of vascular impairment. Using the Scottish Intercollegiate Guidelines Network risk stratification system we found the proportion at moderate and high risk of future ulceration to be 25% and 11%, respectively. At follow-up 16/383 patients (4.2%) developed a new foot ulcer (annual incidence rate of 2.6%). We observed an increasing probability of abnormal vascular and sensory test results (pedal pulse palpation, doppler waveform assessment, 10 g monofilament, vibration perception and neuropathy disability score) with declining eGFR levels. We were unable to show an independent association between new ulceration and reduced eGFR [Odds ratio 1.01; P = 0.64]. CONCLUSION: Our data show the extent of foot complications in a representative sample of diabetes patients in Ireland. Use of eGFR did not improve identification of patients at risk of foot ulceration.

Recent concepts on the pathogenesis of rheumatoid arthritis.

The evidence implicating an immune pathogenesis of the lesions of rheumatoid arthritis is presented under four headings: clinical, histopathological, serological and experimental. This leads to the conclusion that the disease occurs in two phases, an initial phase associated with the presence of an exogenous initiating agent and a chronic, apparently self-prepetuating phase maintained by the presence of an autoanitgen. The microbial nature of the initiating agent is considered and it is concluded that present evidence does not exclude the possibility that no single agent is responsible.

The effect of health status on patients' satisfaction with out-of-hours care provided by a family doctor co-operative.

BACKGROUND: Systems for providing primary care outside normal hours have changed significantly in Europe over the last 20 years. The impetus for this change has come almost entirely from the medical profession, and it is important to consider the patients' perspective. Although patient's satisfaction with out-of-hours care has been studied extensively, the effect of patient's health status on satisfaction level has not been examined previously. OBJECTIVES: The primary objective of this study was to investigate whether health status has an influence on patient satisfaction with out-of-hours care provided by a family doctor co-operative. The secondary objective of this study was to investigate the impact of age, gender, socio-economic status and call outcome on patients' satisfaction with out-of-hours care. METHODS: All patients contacting the service over a designated 24 day period were forwarded a postal questionnaire. Health status was recorded using the Short Form-12 (SF-12) health survey. Patients' satisfaction was measured by using a version of the McKinley questionnaire. RESULTS: The response rate was 55% (531 out of 966). Overall satisfaction levels were high, with 88% of patients rating the service as either excellent or good. Logistic regression, modelling for the simultaneous effects of age, gender, socio-economic status, call outcome and health status on overall satisfaction, found that patients with lower physical and mental health status scores were significantly less likely to be satisfied with their out-of-hours care [odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01-1.07, P = 0.017; and 1.03, 95% CI 1.00-1.06, P = 0.046, respectively]. Patients with higher socio-economic status were also significantly less likely to be satisfied (OR 0.25, 95% CI 0.11-0.55, P = 0.001). Patient's age and gender, and call outcome did not significantly affect overall satisfaction levels. CONCLUSION: Family doctor co-operatives have significantly altered the way out-of-hours care is delivered. Patients with lower health status are significantly less likely to be satisfied with this new form of out-of-hours care. This finding has important implications for the future planning of out-of-hours primary care services.