Valproate prescription to women of childbearing age in English primary care: repeated cross-sectional analyses and retrospective cohort study.

BACKGROUND: Valproate is a teratogenic drug that should be avoided during the preconception period and pregnancy. The aim was to explore general practitioners' (GPs) prescription patterns over time, describe trends, and explore inter-practice variation within primary care. METHODS: We identified women of childbearing age (12-46 years old) in the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) sentinel network. We performed repeated cross-sectional analyses from 2004 to 2018 to determine rates of prescription and a retrospective cohort estimated the prevalence of use of valproate during pregnancy. RESULTS: In 2004, 0.31% (95% Confidence Interval (95%CI):0.18 to 0.44%) women were prescribed valproate, decreasing to 0.16% (95%CI:0.07 to 0.24%) by 2018. Among women with epilepsy, the rate fell from 15.2% (95%CI:14.4 to 16.0%) to 8.8% (95% CI:8.2 to 9.7%) over the same period. In 2018, almost two thirds (62.2%) of women who were prescribed valproate had epilepsy only, whereas bipolar disorder and migraine accounted for 15.8% and 7.4% respectively. Contraceptive prescriptions did not increase over time, and only in 2018 was there greater odds of being prescribed contraception (OR 1.41, 95%CI:1.08 to 1.45). Just under a fifth (19.7%) of women were prescribed valproate during their pregnancy; two out of three of these pregnancies were preceded by folic acid prescription (5 mg). While some practices reduced their rate of valproate prescription, others did not. CONCLUSIONS: Regulatory guidelines have changed GPs' prescription patterns in women of childbearing potential for valproate but not for contraception. Further research is needed to identify the barriers of GPs and women of childbearing potential to undertaking contraception.

Current provision of general practitioner services in or alongside emergency departments in England.

BACKGROUND: In 2017, general practitioners in or alongside the emergency department (GPED), an approach that employs GPs in or alongside the ED to address increasing ED demand, was advocated by the National Health Service in England and supported by capital funding. However, little is known about the models of GPED that have been implemented. METHODS: Data were collected at two time points: September 2017 and December 2019, on the GPED model in use (if any) at 163/177 (92%) type 1 EDs in England. Models were categorised according to a taxonomy as 'inside/integrated', 'inside/parallel', 'outside/onsite' or 'outside/offsite'. Multiple data sources used included: on-line surveys, interviews, case study data and publicly available information. RESULTS: An increase of EDs using GPED was observed from 81% to 95% over the study period. 'Inside/parallel' was the most frequently used model: 30% (44/149) in 2017, rising to 49% (78/159) in 2019. The adoption of 'inside/integrated' models fell from 26% (38/149) to 9% (15/159). Capital funding was received by 87% (142/163) of the EDs sampled. We identified no significant difference between the GPED model adopted and observable characteristics of EDs of annual attendance, 4-hour wait, rurality and deprivation within the population served. CONCLUSION: The majority of EDs in England have now adopted GPED. The availability of capital funding to finance structural changes so that separate GP services can be provided may explain the rise in parallel models and the decrease in integrated models. Further research is required to understand the relative effectiveness of the various models of GPED identified.

[Decrease in minor injury related visits to Emergency Departments coincides with higher numbers of primary care contacts]. / Stijging lichte letsels bij de huisarts valt samen met daling op de SEH.

OBJECTIVE: In the past 10 years, there has been a decrease in the number of patients who report to the Emergency Department (ED) every year for injuries from accidents or violence, especially in the subgroup of patients who did not require hospital admission. We investigated how the number of injury-related emergency department visits and GP contacts evolved over the period 2013-2017. DESIGN: Retrospective observational trend study. METHOD: To calculate the trend in emergency department visits in the Netherlands, we used data from the injury information system (LIS) for the period 2013-2017. To calculate the trend in GP contacts (GP practices as well as GP centres), we used data from the NivelZorgregistraties (Nivel medical records). In order to compare the trends, we distinguished between minor and major injuries. The numbers from the records were extrapolated to numbers for the whole of the Netherlands. RESULTS: In the period studied, the number of patients with minor injuries who visited the ED dropped by 38.5%, while the number of patients with major injuries (fractures and brain injuries) increased by 4.1%. In the same period, the number of GP contacts for minor injuries at GP practices increased by 25% and at GP centres by 43%; the number of primary care contacts for major injuries increased by 5.1% (GP practices) and 31% (GP centres) respectively. CONCLUSION: The role of general practitioners in the treatment of patients with minor injuries is increasing. The trend in major injuries is a better indicator for monitoring accidents and violence in the Netherlands. Conflict of interest and financial support: none declared.

Identification and referral of patients with refractory epilepsy from the primary to the tertiary care interface in New South Wales, Australia.

OBJECTIVES: This mixed-method feasibility study conducted in New South Wales (NSW), Australia, aimed to explore clinical practices around the identification of patients with refractory epilepsy and referral from primary care to Tertiary Epilepsy Centers. The perceptions of general practitioners, neurologists, and adults living with refractory epilepsy were considered. METHODS: Fifty-two data collection events were achieved through 22 semi-structured interviews with six neurologists and 12 adults who currently have, or have had refractory epilepsy, and four family members, 10 clinical observations of patient consultations and 20 surveys with general practitioners. A thematic analysis was conducted on the qualitative data alongside assessment of observational fieldnotes and survey data. FINDINGS: Two main themes emerged: 1) Patient healthcare pathways and care experiences highlighted the complex and deeply contextualized experiences of both patients and healthcare professionals, from first identification of people's seizures, in primary and community care settings, to referral to Tertiary Epilepsy Centers, shedding light on a fragmented, nonstandardized referral process, influenced by both individual and shared-care practices. 2) Factors impacting referrals and patient pathways indicated that onward referral to a Tertiary Epilepsy Center is affected by the knowledge, or the lack thereof, of healthcare professionals regarding treatment options. Barriers include limited person-centered care, shared decision-making, and refractory epilepsy education for healthcare professionals, which can delay patients' disease identification and can hinder speedy referral pathways and processes, in Australia for up to 17 years. In addition, person-centered communication around care pathways is affected by relationships between clinicians, patients, and family members. CONCLUSION: This study has identified a noticeable lack of standardized care across epilepsy-related healthcare sectors, which recognizes a need for developing and implementing clearer epilepsy-related guidelines and Continuing Professional Development in the primary and community care settings. This, however, requires greater collaboration and commitment in the primary, community, and tertiary care sectors to address the ongoing misconceptions around professional roles and responsibilities to optimize shared-care practices. Ultimately, prioritizing person-centered care on both patients' and professionals' agendas, in order to improve satisfaction with care experiences of people living with complex epilepsy.

Sexual dysfunctions and sex therapy: The role of a general practitioner.

BACKGROUND: Medical management is undeniably an important therapeutic intervention for selected sexual dysfunctions, but it does not serve as a stand-alone approach to treat many common sexual dysfunctions such as lack of interest in sex, sexual performance anxiety, inability to reach orgasm or too quick an orgasm. OBJECTIVE: The aim of this article is to highlight the role of general practitioners (GPs) in recognising sexual problems, encourage initiation of conversation about sexual dysfunction with patients and raise awareness of sex therapy and presentations that may benefit from referral to sex therapists. DISCUSSION: GPs in Australia have a significant role in addressing sexual health concerns despite practice-related and doctor-patient-related barriers, thereby promoting the healthy sexuality of Australians. Sex therapy is a specialty comprised of various medical, cognitive, emotional and behavioural interventions. Sex therapists, who are healthcare professionals with tertiary training in human sexuality, can share care with GPs to help individuals and/or couples understand, improve and resolve their sexual dysfunctions.

Management of the antiplatelet therapy during the diagnosis of venous thromboembolism disease: A national survey of French general practitioners' compared to the French vascular physicians' management.

INTRODUCTION: Approximately 15% of patients treated by anticoagulant for a venous thromboembolic event are also treated with antiplatelet therapy; and this association increases the risk of bleeding. The aim of this survey was to evaluate general practitioner's management of antiplatelet therapy at the initiation of anticoagulation, and at six months compared to French vascular physicians' management. METHODS: A questionnaire including 4 clinical situations was established and the physicians were asked to detail antiplatelet and anticoagulant therapy management. From September 2017 to December 2017, an e-mail invitation and a reminder were sent to members of the departmental councils who participated; 218 questionnaires were obtained. RESULTS: Overall, 91.3% of physicians considered that there was an increased risk of bleeding when antiplatelet therapy is associated with anticoagulation. After initiating anticoagulation, 67% of respondents continued antiplatelet therapy, while 30% stopped. Three strategies were used: 49.0% of physicians maintained concomitant antiplatelet therapy with full-dose anticoagulant, both at anticoagulant initiation and at 6 months; 23% of physicians stopped antiplatelet therapy and prescribed full-dose anticoagulant at initiation and at 6 months; 12.4% of physicians prescribed antiplatelet therapy associated with reduced-dose anticoagulation at 6 months regardless of the strategy at anticoagulant initiation. CONCLUSION: One third of general practitioners stopped antiplatelet therapy at the initiation of an anticoagulation for a venous thromboembolic event. Prospective controlled trials are needed to clarify the best way to treat these patients in this situation.

[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.

Australian general practitioners' attitudes to the extraction of research data from electronic health records.

BACKGROUND AND OBJECTIVES: General practice electronic health records (EHRs) are a rich source of primary care data that can be used for important research. The aim of this qualitative study was to analyse the attitudes of Australian general practitioners (GPs) to the use of data extracted from primary care EHRs for clinical research. METHOD: Semi-structured interviews were conducted with 13 Australian GPs. Interviews were recorded, transcribed and thematically analysed. RESULTS: Two main themes emerged. The data custodian role encompassed GPs' determination to maintain privacy, their trust of organisations involved and benefits of research outcomes. The theme of protecting practice resources included concerns about unrecompensed staff time and potential risks to data and systems. DISCUSSION: This study highlights that while Australian GPs have concerns about the use of data stored on their EHRs, they also recognise the benefits of using this data for research purposes. Addressing these concerns could help to ensure that researchers have access to this valuable and rich data resource.

Pharmacogenomic biomarker information differences between drug labels in the United States and Hungary: implementation from medical practitioner view.

Pharmacogenomic biomarker availability of Hungarian Summaries of Product Characteristics (SmPC) was assembled and compared with the information in US Food and Drug Administration (FDA) drug labels of the same active substance (July 2019). The level of action of these biomarkers was assessed from The Pharmacogenomics Knowledgebase database. From the identified 264 FDA approved drugs with pharmacogenomic biomarkers in drug label, 195 are available in Hungary. From them, 165 drugs include pharmacogenomic data disposing 222 biomarkers. Most of them are metabolizing enzymes (46%) and pharmacological targets (41%). The most frequent therapeutic area is oncology (37%), followed by infectious diseases (12%) and psychiatry (9%) (p < 0.00001). Most common biomarkers in Hungarian SmPCs are CYP2D6, CYP2C19, estrogen and progesterone hormone receptor (ESR, PGS). Importantly, US labels present more specific pharmacogenomic subheadings, the level of action has a different prominence, and offer more applicable dose modifications than Hungarians (5% vs 3%). However, Hungarian SmPCs are at 9 oncology drugs stricter than FDA, testing is obligatory before treatment. Out of the biomarkers available in US drug labels, 62 are missing completely from Hungarian SmPCs (p < 0.00001). Most of these belong to oncology (42%) and in case of 11% of missing biomarkers testing is required before treatment. In conclusion, more factual, clear, clinically relevant pharmacogenomic information in Hungarian SmPCs would reinforce implementation of pharmacogenetics. Underpinning future perspective is to support regulatory stakeholders to enhance inclusion of pharmacogenomic biomarkers into Hungarian drug labels and consequently enhance personalized medicine in Hungary.

Psychiatrists as internists: some considerations following a COVID-19 redeployment experience / Psiquiatras como internistas: algunas reflexiones tras una experiencia de reconversión en COVID-19

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[Assessment of the occupational perspectives of general practitioners in a rural area. Results from the study HaMedSi (Hausärzte [GPs] for Medical education in Siegen-Wittgenstein)]. / Einschätzung der beruflichen Perspektive von Hausärzten im ländlichen Raum : Ergebnisse der HaMedSi-Studie (Hausärzte für Medizinerausbildung in Siegen-Wittgenstein).

BACKGROUND: Shortage of general practitioners (GPs), especially in rural areas, is an increasing problem for the German healthcare system. Different approaches are pursued to counteract this development. The study HaMEdSi (Hausärzte (GPs) for Medical Education in Siegen-Wittgenstein) among other things examines the occupational perspectives of the GPs depending on their surgeries' characteristics and draws a realistic picture of how primary care in the region of Siegen-Wittgenstein, representative for many rural regions, will develop over the next few years. METHOD: A survey was conducted among GPs in the region of Siegen-Wittgenstein. This area is a representative rural region in Germany. GPs were amongst other assessed regarding their demographic characteristics and working perspectives. RESULTS: A representative number of GPs took part in the study (n = 85, 54%). For instance, 50.6% of the study participants will no longer be working in practice in 10 years from now and 25% of them assume that their practices be closed after the age-related retirement due to a lack of successor. CONCLUSIONS: The situation in rural areas in reality looks worse than previously estimated in the assessments of the Statutory Health Insurance. Something must be done here to mitigate the impending GPs' shortage. Measures such as promotion of training, employment or settlement in undersupplied regions as well as cross-border promotion, could on the long term compensate for the shortage that threatens many rural regions in Germany.

Preconception and antenatal carrier screening for genetic conditions: The critical role of general practitioners.

BACKGROUND: General practitioners (GPs) provide advice to women and couples before and during pregnancy to optimise the health and wellbeing of couples and their child. Genetic carrier screening can identify the chance of couples having children with recessively inherited genetic conditions. The 2018 federal budget announced Mackenzie's Mission, a $20 million Medical Research Future Fund project investigating how such screening could be offered to all couples who wish to access it. OBJECTIVE: The aim of this paper is to discuss historical and current screening methodologies, options for individuals and couples identified as having a high chance of having a child with a genetic condition, screening guidelines, Mackenzie's Mission and the implications of carrier screening in general practice. DISCUSSION: GPs are crucial to any population-wide genetic carrier screening program and are often the first health professional that women and couples see for preconception and early pregnancy care. Knowledge of genetic screening will be increasingly important as such programs are developed.

Factors related to rural general practitioners supervising general practice registrars in Australia: A national cross-sectional study.

BACKGROUND AND OBJECTIVES: General practice training in Australia is uniquely structured to allow half of all registrars to train in rural areas, in order to increase rural workforce development and access to rural primary care. There is, however, limited national-scale information about rural general practice supervisors who underpin the capacity for rural general practice training. The objective of this research was to explore the factors related to rural general practitioners (GPs) supervising general practice registrars. METHOD: Results were obtained using multivariate analysis of the 2016 Medicine in Australia: Balancing Employment and Life survey data. RESULTS: Overall, 57.8% of rural GPs were supervising registrars. Supervising was strongly related to being Australian-trained, working in a larger practice, and supervising medical students and interns. DISCUSSION: Rural supervising capacity could be increased through supporting GPs in smaller practices to engage in supervision and maintaining the strong involvement of GPs in larger practices. Other important factors may include a greater number of Australian-trained graduates working in rural general practice and increased support for international medical graduates to Fellow and feel confident to supervise.

End-of-life care in rural general practice: how best to support commitment and meet challenges?

BACKGROUND: Few studies have specifically assessed the scope, nature and challenges of palliative and end-of-life care in rural general practice. These knowledge gaps limit the development of evidence-based policies and services for patients in the last months of life. This study aimed to explore the perspectives of general practitioners (GPs) and other stakeholders on rural GPs' involvement and challenges in providing palliative and end-of-life care in regional Australia. METHODS: A qualitative study involving five focus groups with 26 GPs based in rural/regional Western Australia together with 15 individual telephone interviews with four GPs and 11 other stakeholders involved in end-of-life care across Australia. RESULTS: The rural GPs' central role in end-of-life care was recognized by the majority of participants but multiple challenges were also identified. Some challenges were comparable to those found in urban settings but others were more pronounced, including resource limitations and lack of training. Inappropriate payment models discouraged GPs' involvement in some aspects of end-of-life care, such as case conferences and home visits. Compared to GPs in urban settings, those in rural/regional communities often reported closer doctor-patient relationships and better care integration and collaboration. These positive aspects of care could be further developed to enhance service provision. Our study highlighted the importance of regular interactions with other professionals and patients in providing end-of-life care, but many GPs and other stakeholders found such interactions more challenging than the more "technical" aspects of care. CONCLUSIONS: Rural/regional GPs appear to be disproportionately affected by inappropriate payment models and limited resources, but may benefit from closer doctor-patient relationships and better care integration and collaboration relative to urban GPs. Systematic collection of empirical data on GP management at end-of-life is required to build on these strengths and address the challenges.

Undescended testes: What general practitioners need to know

BACKGROUND: Undescended testis (UDT) is a common condition, and parents often primarily present to general practitioners. Management in a timely fashion may reduce the risk of malignancy and infertility OBJECTIVES: The aim of this article is to summarise the key points of assessment and management of UDT in the primary care setting. By reviewing key definitions, such as undescended, retractile, ectopic and ascending testes, we aim to provide updated information for the ongoing management of these conditions. DISCUSSION: The exact pathophysiology of UDT is still an area of ongoing research, and there remains much controversy regarding the exact mechanisms leading to congenital and acquired UDT. Current evidence does not support the use of ultrasonography prior to referral. Hormone therapy has shown no significant benefit, and surgery remains the treatment of choice.