The Contribution of Family Medicine and Family Medicine Leaders to Primary Health Care Development in Americas - from Alma-Ata to Astana and beyond.

Since 2012, the Besrour Centre for Global Family Medicine at the College of Family Physician of Canada has brought together its partners from the Americas annually, to reflect on the evolution of Family Medicine on the continent since Alma-Ata, and to look forward to future challenges. Family doctors are but one element of a strong health system. Family Medicine provides key ingredients to respond to population health needs especially as countries move through the epidemiological transition to face larger burdens of chronic disease and multimorbidity. In this paper, we provide a high-level overview of the state of Family Medicine on the continent. We then analyze trends in the education of family physicians to face this changing landscape, including the emphasis on the leader role of future family physicians. Postgraduate programs in Family Medicine in the Americas are placing increasing emphasis on teaching collaborative care in view of creating truly interdisciplinary health teams for the benefit of patients.

The Contribution of Family Medicine and Family Medicine Leaders to Primary Health Care Development in Americas - from Alma-Ata to Astana and beyond / A contribuição da Medicina de Família e dos líderes em Medicina de Família para o desenvolvimento da Atenção Primária à Saúde nas Américas - de Alma-Ata à Astana e além

Abstract Since 2012, the Besrour Centre for Global Family Medicine at the College of Family Physician of Canada has brought together its partners from the Americas annually, to reflect on the evolution of Family Medicine on the continent since Alma-Ata, and to look forward to future challenges. Family doctors are but one element of a strong health system. Family Medicine provides key ingredients to respond to population health needs especially as countries move through the epidemiological transition to face larger burdens of chronic disease and multimorbidity. In this paper, we provide a high-level overview of the state of Family Medicine on the continent. We then analyze trends in the education of family physicians to face this changing landscape, including the emphasis on the leader role of future family physicians. Postgraduate programs in Family Medicine in the Americas are placing increasing emphasis on teaching collaborative care in view of creating truly interdisciplinary health teams for the benefit of patients.

Resumo Desde 2012, o Centro Besrour de Medicina Global de Família, na Faculdade de Medicina de Família do Canadá, reúne seus parceiros das Américas anualmente para refletir sobre a evolução da Medicina de Família no continente desde Alma-Ata e para os desafios futuros. Os médicos de família são apenas um elemento de um forte sistema de saúde. A Medicina de Família fornece ingredientes-chave para responder às necessidades de saúde da população, especialmente à medida em que os países passam pela transição epidemiológica para enfrentar um fardo maior de doenças crônicas e de multimorbidade. Neste artigo, fornecemos uma visão geral de alto nível do estado da Medicina de Família no continente. Em seguida, analisamos as tendências na educação dos médicos de família para enfrentar esse cenário em mudança, incluindo a ênfase no papel de líder dos futuros médicos de família. Os programas de pós-graduação em Medicina de Família nas Américas estão enfatizando cada vez mais o ensino do cuidado colaborativo, a fim de criar equipes de saúde verdadeiramente interdisciplinares para o benefício dos pacientes.

Trial Protocol: The use of mindfulness-based intervention for improving bracing compliance for adolescent idiopathic scoliosis patients: protocol for a randomised, controlled trial.

INTRODUCTION: Adolescent idiopathic scoliosis (AIS) is the most prevalent deforming orthopaedic condition; it causes significant disability when spinal curves progress beyond 45deg. Bracing is the primary treatment prescribed for adolescents with an immature skeleton who have spinal curves between 25 and 45deg. New evidence suggests that compliance with bracing significantly decreases the progression of high-risk curves to the threshold for surgery. Nonetheless, bracing is a stressful experience. Therefore, interventions that mediate health-related quality of life for AIS patients are of great interest. In the past few decades, numerous studies have documented the benefits of mindfulness training on chronic pain, stress management, anxiety and emotional disorders. Mindfulness might additionally provide AIS patients with psychosocial support. RESEARCH QUESTIONS: This study will investigate the effects of a mindfulness-based intervention on bracing compliance and quality of life among AIS patients with poor bracing compliance. The study also plans to evaluate if the mindfulness-based intervention effect is sustained after the intervention period. The potential mechanism by which mindfulness affects bracing compliance will be explored. DESIGN: Single-blind, two-arm, randomised, controlled trial. PARTICIPANTS AND SETTING: The study will recruit 120 AIS patients aged between 10 and 15 years with non-satisfactory bracing compliance. Patients who have previously practised or are currently practising meditation or mindful yoga or who cannot finish the whole intervention will be excluded. The study will take place at the Jockey Club School of Public Health and Primary Care building. INTERVENTION: Patients in the mindfulness-based intervention group will join weekly sessions for 8 weeks. This program is a short version of a mindfulness-based stress relaxation program to address the specific issues of AIS patients. Two to three experienced instructors will deliver the program. CONTROL: Control group patients will participate in an 8-week physiotherapy exercise program as recommended in the International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) 2011 guideline. MEASUREMENTS: The primary outcome is the 6-month post-intervention total score of bracing compliance. Secondary measures are non-bracing-specific quality of life, bracing-specific quality of life, self-compassion, emotional regulation, mindful awareness and acceptance, self-efficacy, perception of stress, and general measure of health outcome. PROCEDURE: 120 participants will be assigned to either an intervention or control arm by simple randomisation, and the randomisation result will only be revealed once participants have confirmed availability to attend intervention classes. Clinicians of the scoliosis clinic and research staff will be blinded to the treatment allocation. ANALYSIS: ANCOVA will be conducted to compare the effect of mindfulness-based intervention versus physiotherapy exercise on the outcome measures. To investigate significant change over time, linear mixed models analyses will be conducted following the intention-to-treat principle. The R-package lavaan will be used to conduct structural equation modelling to study the potential mechanism of mindfulness. DISCUSSION/SIGNIFICANCE: This will be the first psychosocial intervention study conducted on braced AIS patients with the aim of improving patients' bracing compliance and quality of life. The results from this study will potentially carry significant impact on future AIS treatment by emphasising psychosocial care for braced AIS patients.

A pilot evaluation of Arthritis Self-Management Program by lay leaders in patients with chronic inflammatory arthritis in Hong Kong.

The objectives of this paper are to evaluate the efficacy of a community-based lay-led Arthritis Self-Management Program (ASMP) among patients with chronic inflammatory arthritis and evaluate the effectiveness of "shared care collaboration" between hospital and community. We trained 17 lay leaders and recruited patients with chronic inflammatory arthritis via a new shared-care model between hospital rheumatology centers and community organizations. Participants were allocated to interventional group or a wait list control group. Evaluations were completed before, after (6 weeks), and 3 months after ASMP. We performed analysis of covariance with adjustment with age, sex, marital status, education, employment, duration of illness, and disability at baseline. A total of 65 participants and 32 controls completed the study. The mean (SD) age and duration of illness were 52.0 (11.4) and 5.6 (7.3) years, 90.7 % were female, 80.4 % had rheumatoid arthritis; 25.8, 53.6, and 12.4 % referrals were from hospitals, community organizations, and patient self-help groups, respectively. The interventional group had significantly less pain (p = 0.049 at 6 weeks), used more cognitive coping methods (p = 0.008 at 6 weeks, p = 0.041 at 3 months) and practiced more aerobic exercise (p = 0.049 at 6 weeks, p = 0.008 at 3 months) after adjustment of covariance. The interventional group had a trend of improvement in self-efficacy, fatigue, self-rated health, and health distress. A community-based lay-led ASMP showed positive beneficial effects on participants with chronic inflammatory arthritis. Shared-care collaboration between hospitals, community organizations, and patient self-help groups was demonstrated.

Can botulinum toxin decrease carer burden in long term care residents with upper limb spasticity? A randomized controlled study.

OBJECTIVE: To evaluate whether botulinum toxin can decrease the burden for caregivers of long term care patients with severe upper limb spasticity. METHOD: This was a double-blind placebo-controlled trial with a 24-week follow-up period. SETTING: A 250-bed long term care hospital, the infirmary units of 3 regional hospitals, and 5 care and attention homes. PARTICIPANTS: Participants included 55 long term care patients with significant upper limb spasticity and difficulty in basic upper limb care. INTERVENTIONS: Patients were randomized into 2 groups that received either intramuscular botulinum toxin A or saline. MAIN OUTCOME MEASURES: The primary outcome measure was provided by the carer burden scale. Secondary outcomes included goal attainment scale, measure of spasticity by modified Ashworth score, passive range of movement for shoulder abduction, and elbow extension and finger extension. Pain was assessed using the Pain Assessment in Advanced Dementia Scale. RESULTS: A total of 55 patients (21 men; mean age = 69, SD =18) were recruited. At week 6 post-injection, 18 (60%) of 30 patients in the treatment group versus 2 (8%) of 25 patients in the control group had a significant 4-point reduction of carer burden scale (P < .001). There was also significant improvement in the goal attainment scale, as well as the modified Ashworth score, resting angle, and passive range of movement of the 3 regions (shoulder, elbow, and fingers) in the treatment group which persisted until week 24. There were also fewer spontaneous bone fractures after botulinum toxin injection, although this did not reach statistical significance. No significant difference in Pain Assessment in Advanced Dementia scale was found between the 2 groups. No serious botulinum toxin type A-related adverse effects were reported. CONCLUSION: Long term care patients who were treated for upper limb spasticity with intramuscular injections of botulinum toxin A had a significant decrease in the caregiver burden. The treatment was also associated with improved scores on patient-centered outcome measures.