Australian general practitioners' perceptions of the barriers and opportunities for community-based care of patients with viral hepatitis: a mixed methods study.

Introduction Engagement of general practitioners (GPs) is essential to improving rates of diagnosis and treatment of viral hepatitis, as traditional tertiary hospital-based models of care often face challenges. Aim We investigated Australian general practitioners' perceptions of a community-based model of care for patients with viral hepatitis. Methods We conducted a mixed methods study using survey questionnaires (23 GPs) and an open-ended interview guide (10 GPs) at primary care clinics in Brisbane, Queensland, Australia. Quantitative data were analysed using descriptive statistics in Stata 15.1 and qualitative data were analysed using thematic analysis following an inductive approach. Results Patient loss to follow up and high cost of diagnostic tests were identified as the biggest challenges to providing care for patients with viral hepatitis. Most GPs interviewed believe a more community-based model of care with support to GPs may improve uptake of care and increase both GP and patient engagement. General practitioners felt a community-based model of care could also improve viral hepatitis testing and follow-up rates. Discussion For Australian GPs, improving patient retention and diagnostics access were key pressure points in the viral hepatitis care pathway. A broader and more profound capacity-building allows community-based viral hepatitis care to be sustainable.

Ripple effects: integrating international medical graduates from refugee backgrounds into the health system in Australia.

The field of 'refugee health' is generally understood in terms of the efforts of health professionals from a host country to provide care for humanitarian entrants. This paper attempts to undermine that idea, focusing instead on the service that health workers from refugee background communities are able to render, both to their own communities and to broader society, when barriers to their participation are made more equitable. The point of departure for this Practice paper is the 2019 pilot 'Observership Program' that was initiated by Mater Refugee Health in Brisbane, Australia. This was in response to, and in collaboration with, international medical graduates from refugee backgrounds. The two doctors who advocated for the programme had already independently embarked on a series of advocacy initiatives aimed at facilitating health workforce participation for members of their communities. In what follows we: outline the barriers to their medical registration and employment in Queensland, Australia; describe the process of setting up a 9-month clinical observership for two participants; and we reflect on the implications of the programme from a health policy and systems perspective. Ultimately, our contention is that because health systems are complex and adaptive, increased health workforce participation by members of marginalised communities has the potential to change the culture of the health system, making it more adept and responsive. Such, we propose, are the 'ripple effects' of addressing the obstacles to health workforce participation by members of refugee background communities.

Reconceptualising specialisation: integrating refugee health in primary care.

People from a refugee background have significant unmet health needs including complex physical and psycho-social presentations. They can experience low trust, unfamiliarity with the health system and reliance on family and friends to access care. To address these needs, Australia has specialised refugee health services in each state and territory. The majority of these services transition patients to primary care, but this transition, although necessary, is difficult. Most primary care and specialised health professionals share a high degree of commitment to refugee patients; however, despite best efforts, there are gaps. More integrated health services can start to address gaps and promote continuity of care. A previous study has described 10 principles that are associated with successful integration; this paper references five of those principles (continuum of care, patient focus, geographic coverage, information systems and governance) to describe and map out the outcomes of an integrated model of care designed to deliver specialist refugee health in primary care. The Co-location Model is a partnership between a refugee health service, Primary Health Networks, a settlement agency and general practices. It has the potential to deliver benefits for patients, greater satisfaction for health professionals and gains for the health system.

Improving the effectiveness of interpreted consultations: Australian interpreter, general practitioner and patient perspectives.

Healthcare consultations with patients lacking English proficiency are challenging for all parties, even in Australian primary care where the engagement of interpreters is encouraged and fully subsidised. Our objective was to understand these challenges from the perspectives of interpreters, patients and general practitioners in order to improve the effectiveness of interpreted consultations. Our investigator team approached the interpreted consultation as an interprofessional collaboration. A convenience sample of seven general practitioners, eight health interpreters and six representatives from culturally and linguistically diverse communities (representing the patient perspective) participated in three separate focus group discussions, lasting 60-90 min each, exploring participant experiences with healthcare consultations in which interpreters were present. Two semistructured interviews were undertaken subsequently with three additional community representatives purposively recruited to increase participant diversity. Data were collected in 2016 and analysed inductively using a method of constant comparison to identify, and reach consensus on, key emerging themes. All participant groups emphasised the importance of working with trained interpreters, rather than relying on family interpreters or a doctor's own second language skills. Although participants reported experiences of effective interpreted consultations, other reports suggested that some doctors are unaware of, or have difficulty following, accepted guidelines about speech, gaze and turn-taking. Challenges identified in relation to interpreted consultations fell into the five themes of contextual constraints, consultation complexity, communication difficulties, the interpreter role and collaboration. Some general practitioner participants appeared to be unsure and anxious about the etiquette of interpreted consultations, and there was some confusion between and within participant groups about interpreter roles and professional codes. A briefing session prior to the consultation, clarifying the roles of all parties, including any family or bicultural workers present, may help to establish respectful, flexible and effective interprofessional collaborations and to encourage participants to directly address any problems during the consultation.

Delayed antibiotic prescriptions for respiratory infections.

BACKGROUND: Concerns exist regarding antibiotic prescribing for respiratory tract infections (RTIs) owing to adverse reactions, cost, and antibacterial resistance. One proposed strategy to reduce antibiotic prescribing is to provide prescriptions, but to advise delay in antibiotic use with the expectation that symptoms will resolve first. This is an update of a Cochrane Review originally published in 2007, and updated in 2010 and 2013. OBJECTIVES: To evaluate the effects on clinical outcomes, antibiotic use, antibiotic resistance, and patient satisfaction of advising a delayed prescription of antibiotics in respiratory tract infections. SEARCH METHODS: For this 2017 update we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, Issue 4, 2017), which includes the Cochrane Acute Respiratory Infection Group's Specialised Register; Ovid MEDLINE (2013 to 25 May 2017); Ovid Embase (2013 to 2017 Week 21); EBSCO CINAHL Plus (1984 to 25 May 2017); Web of Science (2013 to 25 May 2017); WHO International Clinical Trials Registry Platform (1 September 2017); and ClinicalTrials.gov (1 September 2017). SELECTION CRITERIA: Randomised controlled trials involving participants of all ages defined as having an RTI, where delayed antibiotics were compared to immediate antibiotics or no antibiotics. We defined a delayed antibiotic as advice to delay the filling of an antibiotic prescription by at least 48 hours. We considered all RTIs regardless of whether antibiotics were recommended or not. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures. Three review authors independently extracted and collated data. We assessed the risk of bias of all included trials. We contacted trial authors to obtain missing information. MAIN RESULTS: For this 2017 update we added one new trial involving 405 participants with uncomplicated acute respiratory infection. Overall, this review included 11 studies with a total of 3555 participants. These 11 studies involved acute respiratory infections including acute otitis media (three studies), streptococcal pharyngitis (three studies), cough (two studies), sore throat (one study), common cold (one study), and a variety of RTIs (one study). Five studies involved only children, two only adults, and four included both adults and children. Six studies were conducted in a primary care setting, three in paediatric clinics, and two in emergency departments.Studies were well reported, and appeared to be of moderate quality. Randomisation was not adequately described in two trials. Four trials blinded the outcomes assessor, and three included blinding of participants and doctors. We conducted meta-analysis for antibiotic use and patient satisfaction.We found no differences among delayed, immediate, and no prescribed antibiotics for clinical outcomes in the three studies that recruited participants with cough. For the outcome of fever with sore throat, three of the five studies favoured immediate antibiotics, and two found no difference. For the outcome of pain related to sore throat, two studies favoured immediate antibiotics, and three found no difference. One study compared delayed antibiotics with no antibiotic for sore throat, and found no difference in clinical outcomes.Three studies included participants with acute otitis media. Of the two studies with an immediate antibiotic arm, one study found no difference for fever, and the other study favoured immediate antibiotics for pain and malaise severity on Day 3. One study including participants with acute otitis media compared delayed antibiotics with no antibiotics and found no difference for pain and fever on Day 3.Two studies recruited participants with common cold. Neither study found differences for clinical outcomes between delayed and immediate antibiotic groups. One study favoured delayed antibiotics over no antibiotics for pain, fever, and cough duration (moderate quality evidence for all clinical outcomes - GRADE assessment).There were either no differences for adverse effects or results favoured delayed antibiotics over immediate antibiotics (low quality evidence - to GRADE assessment) with no significant differences in complication rates. Delayed antibiotics resulted in a significant reduction in antibiotic use compared to immediate antibiotics prescription (odds ratio (OR) 0.04, 95% confidence interval (CI) 0.03 to 0.05). However, a delayed antibiotic was more likely to result in reported antibiotic use than no antibiotics (OR 2.55, 95% CI 1.59 to 4.08) (moderate quality evidence - GRADE assessment).Patient satisfaction favoured delayed over no antibiotics (OR 1.49, 95% CI 1.08 to 2.06). There was no significant difference in patient satisfaction between delayed antibiotics and immediate antibiotics (OR 0.65, 95% CI 0.39 to 1.10) (moderate quality evidence - GRADE assessment).None of the included studies evaluated antibiotic resistance. AUTHORS' CONCLUSIONS: For many clinical outcomes, there were no differences between prescribing strategies. Symptoms for acute otitis media and sore throat were modestly improved by immediate antibiotics compared with delayed antibiotics. There were no differences in complication rates. Delaying prescribing did not result in significantly different levels of patient satisfaction compared with immediate provision of antibiotics (86% versus 91%) (moderate quality evidence). However, delay was favoured over no antibiotics (87% versus 82%). Delayed antibiotics achieved lower rates of antibiotic use compared to immediate antibiotics (31% versus 93%) (moderate quality evidence). The strategy of no antibiotics further reduced antibiotic use compared to delaying prescription for antibiotics (14% versus 28%). Delayed antibiotics for people with acute respiratory infection reduced antibiotic use compared to immediate antibiotics, but was not shown to be different to no antibiotics in terms of symptom control and disease complications. Where clinicians feel it is safe not to prescribe antibiotics immediately for people with respiratory infections, no antibiotics with advice to return if symptoms do not resolve is likely to result in the least antibiotic use while maintaining similar patient satisfaction and clinical outcomes to delaying prescription of antibiotics. Where clinicians are not confident in using a no antibiotic strategy, a delayed antibiotics strategy may be an acceptable compromise in place of immediate prescribing to significantly reduce unnecessary antibiotic use for RTIs, and thereby reduce antibiotic resistance, while maintaining patient safety and satisfaction levels.Editorial note: As a living systematic review, this review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

A feasibility study to improve practice nurses' competence and confidence in providing care for mothers and infants.

BACKGROUND: Postnatal care is best provided in primary health care settings, yet Practice Nurses (PNs) lack relevant training and report difficulty in providing postnatal care. AIM: To evaluate the feasibility of a pilot educational intervention in improving PN competence and confidence to care for mothers and infants in the first postnatal year. DESIGN: A feasibility study. METHODS: PNs were recruited from selected general practices Queensland, Australia to undertake the pilot educational intervention that included a pre-intervention survey, two-day education program, program evaluation and completion of a practice journal. RESULTS: Thirteen PNs from three general practices participated, with 31% completing all study components. Evaluation of the intervention was positive and all participants reported increased confidence and competence in providing postnatal care. Following detailed consideration of feasibility (process, resource, management and scientific assessment) we propose that changes to intervention delivery and data collection should be incorporated into a larger trial.

Early insights into the neurobiology of pain in sickle cell disease: A systematic review of the literature.

Novel insights into the neurobiology of sickle cell disease (SCD) pain have recently been discovered. We systematically reviewed the literature focusing on original research that examined the biology of pain in SCD and/or addressed assessment or treatment of neuropathic pain in SCD. This review of 15 articles that met inclusion criteria provides epidemiological, basic, and clinical data that support central and/or peripheral nervous system abnormalities likely contribute to sickle cell pain. Continued basic and clinical investigation into pain neurobiology is imperative to translate these discoveries into novel ways to assess and treat neuropathic pain and decrease patient suffering.

The use of neuropathic pain drugs in children with sickle cell disease is associated with older age, female sex, and longer length of hospital stay.

Although neuropathic pain is increasingly recognized in sickle cell disease (SCD), it is unknown how neuropathic pain drugs are used in children with SCD. Thus, we investigated use of these drugs and hypothesized older age and female sex are associated with increased neuropathic drug use and the use of these drugs is associated with longer length of stay. We analyzed the Pediatric Health Information System (2004 to 2009) including all inpatient visits aged 0 to 18 years with any SCD-related (all genotypes) discharge diagnosis. To limit confounding we excluded psychiatric and seizure visits. Antiepileptics, tricyclic antidepressants, and selective serotonin reuptake inhibitors were drugs of interest. Generalized Estimating Equations determined the impact of age and sex on neuropathic drug use and the impact of neuropathic drug use on length of stay. We analyzed 53,557 visits; 2.9% received≥1 neuropathic drugs. The odds of receiving a neuropathic drug increased significantly with age (reference group, 0 to 4 y: 5 to 10, odds ratio [OR], 5.7; 11 to 14: OR, 12.5; 15 to 18: OR, 22.8; all P<0.0001] and female sex (OR, 1.5; P=0.001). Neuropathic drug use was associated with longer length of stay (risk ratio, 8.3; P<0.0001). Neuropathic drug use in children with SCD was associated with older age, female sex, and longer length of stay.

Antibiotics for bronchiolitis in children under two years of age.

BACKGROUND: Bronchiolitis is a serious, potentially life-threatening respiratory illness commonly affecting babies. It is often caused by respiratory syncytial virus (RSV). Antibiotics are not recommended for bronchiolitis unless there is concern about complications such as secondary bacterial pneumonia or respiratory failure. Nevertheless, they are often used. OBJECTIVES: To evaluate the effectiveness of antibiotics for bronchiolitis in children under two years of age compared to placebo or other interventions. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 6), which includes the Cochrane Acute Respiratory Infection Group's Specialised Register, and the Database of Abstracts of Reviews of Effects, MEDLINE (1966 to June 2014), EMBASE (1990 to June 2014) and Current Contents (2001 to June 2014). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing antibiotics to placebo in children under two years diagnosed with bronchiolitis, using clinical criteria (including respiratory distress preceded by coryzal symptoms with or without fever). Primary clinical outcomes included time to resolution of signs or symptoms (pulmonary markers included respiratory distress, wheeze, crepitations, oxygen saturation and fever). Secondary outcomes included hospital admissions, length of hospital stay, readmissions, complications or adverse events and radiological findings. DATA COLLECTION AND ANALYSIS: Two review authors independently analysed the search results. MAIN RESULTS: We included seven studies with a total of 824 participants. The results of these seven included studies were often heterogeneous, which generally precluded meta-analysis, except for deaths, length of supplemental oxygen use and length of hospital admission.In this update, we included two new studies (281 participants), both comparing azithromycin with placebo. They found no significant difference for length of hospital stay, duration of oxygen requirement and readmission. These results were similar to an older study (52 participants) that demonstrated no significant difference comparing ampicillin and placebo for length of illness.One small study (21 participants) with higher risk of bias randomised children with proven RSV infection to clarithromycin or placebo and found a trend towards a reduction in hospital readmission with clarithromycin.The three studies providing adequate data for days of supplementary oxygen showed no difference between antibiotics and placebo (pooled mean difference (MD) (days) -0.20; 95% confidence interval (CI) -0.72 to 0.33). The three studies providing adequate data for length of hospital stay, similarly showed no difference between antibiotics (azithromycin) and placebo (pooled MD (days) -0.58; 95% CI -1.18 to 0.02).Two studies randomised children to intravenous ampicillin, oral erythromycin and control and found no difference for most symptom measures.There were no deaths reported in any of the arms of the seven included studies. No other adverse effects were reported. AUTHORS' CONCLUSIONS: This review did not find sufficient evidence to support the use of antibiotics for bronchiolitis, although research may be justified to identify a subgroup of patients who may benefit from antibiotics. Further research may be better focused on determining the reasons that clinicians use antibiotics so readily for bronchiolitis, how to reduce their use and how to reduce clinician anxiety about not using antibiotics.

Neuropathic pain in patients with sickle cell disease.

BACKGROUND: Despite the suggestion of a neuropathic component to sickle cell disease (SCD) pain, there are minimal data on the systematic assessment of neuropathic pain in patients with SCD. Neuropathic pain is defined as pain primarily initiated by dysfunction of the peripheral or central nervous system. PROCEDURE: In a cross-sectional study, we used the painDETECT questionnaire, a one-page validated neuropathic pain screening tool, to determine the presence of neuropathic pain in patients with SCD and to evaluate the relationship between neuropathic pain, age, and gender. We hypothesized that 20% of patients with SCD will experience neuropathic pain and that neuropathic pain will be associated with older age and female gender. The completed painDETECT questionnaire yields a total score between 0 and 38 (≥ 19 = definite neuropathic pain, 13-18 = probable neuropathic pain, ≤ 12 = no neuropathic pain). Scores ≥ 13 were designated as having evidence of neuropathic pain. RESULTS: A total of 56 patients participated. Median age was 20.3 years and 77% were female. We found 37% of patients had evidence of neuropathic pain. Age was positively correlated with total score (r = 0.43; P = 0.001) suggesting older patients experience more neuropathic pain. Females had higher mean total scores (13 vs. 8.4; P = 0.04). Significantly more patients with neuropathic pain were taking hydroxyurea (90% vs. 59%; P = 0.015). Despite 37% of patients experiencing neuropathic pain, only 5% were taking a neuropathic pain drug. CONCLUSIONS: Neuropathic pain exists in SCD. Valid screening tools can identify patients that would benefit from existing and future neuropathic pain therapies and could determine the impact of these therapies.

Caring for refugees in general practice: perspectives from the coalface.

This qualitative research project explored the experiences of primary health care providers working with newly arrived refugees in Brisbane. Data from 36 participants (20 general practitioners, five practice nurses and 11 administrative staff) involved in five focus groups and four semi-structured interviews were analysed. The results indicated that despite difficulties, providers are committed and enthusiastic about working with refugees. The flexibility of the general practice setting enables innovative approaches. The establishment of a specialised refugee health service in Brisbane has improved providers' capacity to deliver refugee health care. However, most practices continue to feel isolated as they search for solutions, and the need for greater supports and a more coordinated approach to care were emphasised. The themes of communication, knowledge and practice and health care systems encapsulated the factors that influence health care providers' ability to care for refugees and provide a framework for improving available supports. Australian primary health care is currently undergoing great change, which provides an opportunity to make significant gains in the provision of care for refugees and other minority groups within our community. As health care reforms are implemented it is essential that they are responsive to the expressed needs of health care providers working in these areas.

A is for aphorism--'good judgment comes from experience; experience comes from bad judgment'.

'Good judgment comes from experience; experience comes from bad judgment'. This aphorism was attributed to Dr Kerr L White. It makes sense. The physician who exercises bad judgement and makes poor decisions is likely to experience more disease, more complications and, through those experiences, hopefully develop better judgement. Unfortunately, when it comes to the practice of medicine, that experience can come at a high cost. So is there any truth to Dr White's comment?

Delayed antibiotics for respiratory infections.

BACKGROUND: Concerns exist regarding antibiotic prescribing for acute respiratory tract infections (ARTIs) owing to adverse reactions, cost and antibacterial resistance. One strategy to reduce antibiotic prescribing is to provide prescriptions but to advise delay in the hope symptoms will resolve first. This is an update of a Cochrane Review originally published in 2007 and updated in 2010. OBJECTIVES: To evaluate the use of delayed antibiotics compared to immediate or no antibiotics as a prescribing strategy for ARTIs. We evaluated clinical outcomes including duration and severity measures for pain, malaise, fever, cough and rhinorrhoea in sore throat, acute otitis media, bronchitis (cough) and the common cold. We also evaluated the outcomes of antibiotic use, patient satisfaction, antibiotic resistance and re-consultation rates and use of alternative therapies. SEARCH METHODS: We searched CENTRAL (The Cochrane Library 2013, Issue 2), which includes the Acute Respiratory Infection Group's Specialised Register; Ovid MEDLINE (January 1966 to February Week 3 2013); Ovid MEDLINE In-Process & Other Non-Indexed Citations (28 February 2013); EMBASE (1990 to 2013 Week 08); Science Citation Index - Web of Science (2007 to May 2012) and EBSCO CINAHL (1982 to 28 February 2013). SELECTION CRITERIA: Randomised controlled trials (RCTs) involving participants of all ages defined as having an ARTI, where delayed antibiotics were compared to antibiotics used immediately or no antibiotics. DATA COLLECTION AND ANALYSIS: Three review authors independently extracted and collected data. Important adverse effects, including adverse effects of antibiotics and complications of disease, were included as secondary outcomes. We assessed the risk of bias of all included trials. We contacted trial authors to obtain missing information where available. MAIN RESULTS: Ten studies, with a total of 3157 participants, were included in this review. Heterogeneity of the 10 included studies and their results generally precluded meta-analysis with patient satisfaction being an exception.There was no difference between delayed, immediate and no prescribed antibiotics for the clinical outcomes evaluated in cough and common cold. In patients with acute otitis media (AOM) and sore throat immediate antibiotics were more effective than delayed for fever, pain and malaise in some studies. There were only minor differences in adverse effects with no significant difference in complication rates.Delayed antibiotics resulted in a significant reduction in antibiotic use compared to immediate antibiotics. A strategy of no antibiotics resulted in least antibiotic use.Patient satisfaction favoured immediate antibiotics over delayed (odds ratio (OR) 0.52; 95% confidence interval (CI) 0.35 to 0.76). Delayed and no antibiotics had similar satisfaction rates with both strategies achieving over 80% satisfaction (OR 1.44; 95% CI 0.99 to 2.10).There was no difference in re-consultation rates for immediate and delayed groups.None of the included studies evaluated antibiotic resistance. AUTHORS' CONCLUSIONS: Most clinical outcomes show no difference between strategies. Delay slightly reduces patient satisfaction compared to immediate antibiotics (87% versus 92%) but not compared to none (87% versus 83%). In patients with respiratory infections where clinicians feel it is safe not to prescribe antibiotics immediately, no antibiotics with advice to return if symptoms do not resolve is likely to result in the least antibiotic use, while maintaining similar patient satisfaction and clinical outcomes to delayed antibiotics.

Subhepatically located appendicitis due to adhesions: a case report.

INTRODUCTION: Acute appendicitis occurs frequently and is a major indication for acute abdominal surgery. Subhepatic appendicitis has rarely been reported and is more difficult to diagnose. CASE PRESENTATION: A 71-year-old man with multiple medical comorbidities presented with undifferentiated right abdominal pain. Diagnostic difficulty was encountered due to subhepatic mal-location of the appendix and subsequently atypical presentation for acute appendicitis. CONCLUSION: Subhepatic anatomical location of the appendix makes it more difficult to diagnose acute appendicitis at any age, including in older adults.

The Building Partnerships Program: An Approach to Community-Based Learning for Medical Students in Australia.

The Building Partnerships Program at the University of Queensland, Australia seeks to address the dual challenge of preparing doctors who are responsive to the community while providing a meaningful context for social sciences learning. Through partnerships with a diverse range of community agencies, the program offers students opportunities to gain non-clinical perspectives on health and illness through structured learning activities including: family visits; community agency visits and attachments; and interview training. Students learn first-hand about psychosocial influences on health and how people manage health problems on a day-to-day basis. They also gain insights into the work of community agencies and how they as future doctors might work in partnership with them to enhance patient care. We outline the main components of the program, identify challenges and successes from student and community agency perspectives, and consider areas that invite further development.