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2.
BMJ ; 367: l5922, 2019 11 05.
Artigo em Inglês | MEDLINE | ID: mdl-31690561

RESUMO

OBJECTIVE: To investigate the clinical effectiveness and safety of stand alone and blended internet based vestibular rehabilitation (VR) in the management of chronic vestibular syndromes in general practice. DESIGN: Pragmatic, three armed, parallel group, individually randomised controlled trial. SETTING: 59 general practices in the Netherlands. PARTICIPANTS: 322 adults aged 50 and older with a chronic vestibular syndrome. INTERVENTIONS: Stand alone VR comprising a six week, internet based intervention with weekly online sessions and daily exercises (10-20 minutes a day). In the blended VR group, the same internet based intervention was supplemented by face-to-face physiotherapy support (home visits in weeks 1 and 3). Participants in the usual care group received standard care from a general practitioner, without any restrictions. MAIN OUTCOME MEASURES: The primary outcome was vestibular symptoms after six months as measured by the vertigo symptom scale-short form (VSS-SF range 0-60, clinically relevant difference ≥3 points). Secondary outcomes were dizziness related impairment, anxiety, depressive symptoms, subjective improvement of vestibular symptoms after three and six months, and adverse events. RESULTS: In the intention-to-treat analysis, participants in the stand alone and blended VR groups had lower VSS-SF scores at six months than participants in the usual care group (adjusted mean difference -4.1 points, 95% confidence interval -5.8 to -2.5; and -3.5 points, -5.1 to -1.9, respectively). Similar differences in VSS-SF scores were seen at three months follow-up. Participants in the stand alone and blended VR groups also experienced less dizziness related impairment, less anxiety, and more subjective improvement of vestibular symptoms at three and six months. No serious adverse events related to online VR occurred during the trial. CONCLUSION: Stand alone and blended internet based VR are clinically effective and safe interventions to treat adults aged 50 and older with a chronic vestibular syndrome. Online VR is an easily accessible form of treatment, with the potential to improve care for an undertreated group of patients in general practice. TRIAL REGISTRATION: Netherlands Trial Register NTR5712.


Assuntos
Medicina Geral/métodos , Modalidades de Fisioterapia , Qualidade de Vida , Telemedicina/métodos , Doenças Vestibulares/reabilitação , Idoso , Doença Crônica/psicologia , Doença Crônica/reabilitação , Feminino , Humanos , Internet , Masculino , Pessoa de Meia-Idade , Países Baixos , Síndrome , Resultado do Tratamento , Doenças Vestibulares/diagnóstico , Doenças Vestibulares/psicologia
6.
Presse Med ; 48(7-8 Pt 1): 767-779, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31303371

RESUMO

OBJECTIVES: In France, too few general practitioners (GP) follow the training about suicide prevention and risk. This study aimed at reviewing international publications regarding GP's training on suicide risk, in order to inform us about the training practices in the world and potentially discover new methodologies. METHODS: We performed bibliographic databases searches on GPs training about suicide prevention and risk, for practicing GPs, excluding studies about particular population groups, following the PRISMA statement guidelines. Training duration, educational program, content, time of assessment, tools, and information about train the trainers or kirkpatrick's level were identified for each selected study. RESULTS: This review revealed that there is no consensus on the training program or on the assessment tools in GP's training about suicide prevention and risk. Nevertheless, it reveals a similar framework including a theoretical part, with a fundamental knowledge content, and an interactive part. CONCLUSION: If reaching standardized training practices seems difficult to achieve, standardizing assessment tools might be a relevant purpose. Indeed, using the same tools would allow proper training comparison. Practically speaking, this review inspired us in the implementation of in situ training and convincing us to undertake a French translation of an assessment scale.


Assuntos
Medicina Geral/educação , Clínicos Gerais/educação , Suicídio/prevenção & controle , Estudos de Casos e Controles , Educação Médica Continuada/métodos , Educação Médica Continuada/normas , Educação Médica Continuada/estatística & dados numéricos , Avaliação Educacional , França/epidemiologia , Medicina Geral/métodos , Medicina Geral/normas , Medicina Geral/estatística & dados numéricos , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Aprendizagem Baseada em Problemas/métodos , Aprendizagem Baseada em Problemas/normas , Suicídio/estatística & dados numéricos , Tentativa de Suicídio/prevenção & controle , Tentativa de Suicídio/estatística & dados numéricos
7.
J Clin Nurs ; 28(19-20): 3680-3690, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31216390

RESUMO

AIMS AND OBJECTIVES: To explore how community nurses experience the collaboration with general practitioners and specialist palliative home care team nurses in palliative home care and the perceived factors influencing this collaboration. BACKGROUND: The complexity of, and the demand for, palliative home care is increasing. Primary palliative care is provided by community nurses and general practitioners, often in collaboration with palliative home care team nurses. Although these professionals may each individually be part of a fixed team, a new temporary team is often composed for every new palliative patient. These membership changes, referred to as team membership fluidity, challenge professionals to work effectively. DESIGN AND METHODS: A qualitative research design, using semi-structured interviews with community nurses. Participant selection happened through regional palliative care networks in Belgium. The network's palliative home care team nurses selected community nurses with whom they recently collaborated. Twenty interviews were conducted. A constant comparative analysis approach was used. Consolidated criteria for reporting qualitative research guidelines were followed. RESULTS: Formal interprofessional team meetings were not common practice. The other's approachability and knowing each other positively influenced the collaboration. Time constraints, the general practitioners' lack of expertise, communication style, hierarchy perception and income dependency negatively influenced the collaboration with general practitioners and determined palliative home care team nurses' involvement. The coping strategies of community nurses balanced between a behaviour focused to the patient and to the professional relationship. Specialist palliative home care team nurses were relied upon for their expertise but also to mediate when community nurses disagreed with general practitioners. CONCLUSION: Community nurses showed to be highly adaptable within the fluid team. Strikingly, dynamics described in the doctor-nurse game 50 years ago are still present today and affect the interprofessional communication. Interprofessional education interventions can contribute to improved interprofessional collaboration. RELEVANCE TO CLINICAL PRACTICE: The study findings uncovered critical knowledge gaps in interprofessional collaboration in palliative home care. Insights are relevant for and related to professional well-being and workplace learning.


Assuntos
Relações Interprofissionais , Cuidados Paliativos , Relações Médico-Enfermeiro , Bélgica , Enfermagem em Saúde Comunitária/métodos , Feminino , Medicina Geral/métodos , Enfermagem de Cuidados Paliativos na Terminalidade da Vida/métodos , Humanos , Masculino , Pesquisa Qualitativa
8.
Nutrients ; 11(6)2019 Jun 11.
Artigo em Inglês | MEDLINE | ID: mdl-31212668

RESUMO

There is a lack of dietitians trained to deliver the low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet (LFD) for irritable bowel syndrome (IBS). Many patients receive nutritional information from general practitioners (GPs) or gastroenterologists (GEs). Since the LFD is dietitian-led, the aim of this research was to qualitatively explore the effects of GP- and GE-delivered LFD information, in IBS self-management. Semi-structured interviews were conducted in a purposive sample of 8 people with IBS (6 female), who used the LFD as their primary treatment. Interpretive Phenomenological Analysis (IPA) was used to develop themes on the lived experience of the participant's use of LFD information from GPs and GEs. This information was perceived as trustworthy but simplistic; often just "food lists" with little personalisation to meet individual needs and difficult to apply in "real life". The information required substantial interpretation and the familial and social effects of implementation were not addressed in the materials provided. Supplementary digital resources were regarded as more practical but the participants expressed concern in relation to the validity of these materials. The findings in this study support current clinical guidelines proposed by both the National Institute for Health and Care Excellence and the British Dietetic Association that the LFD should be considered a dietitian-led only intervention.


Assuntos
Dieta com Restrição de Carboidratos/psicologia , Dietética/métodos , Síndrome do Intestino Irritável/psicologia , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Educação de Pacientes como Assunto/métodos , Adulto , Feminino , Gastroenterologistas , Gastroenterologia/métodos , Medicina Geral/métodos , Clínicos Gerais , Humanos , Síndrome do Intestino Irritável/dietoterapia , Masculino , Pessoa de Meia-Idade , Pesquisa Qualitativa , Adulto Jovem
10.
Dtsch Med Wochenschr ; 144(8): e51-e57, 2019 04.
Artigo em Alemão | MEDLINE | ID: mdl-30986856

RESUMO

BACKGROUND: To examine clinical, comorbidity and demographic aspects of gout and to explore the routine clinical practice of gout treatment among general practitioners (G.P.'s) in southwest Germany. METHODS: Gout specific questionnaires were sent to all G.P.'s in Rhineland Palatinate (RL-P), through the Panel physicians' Association. Questionnaires consisted of items exploring epidemiological, medication and comorbidity data. Moreover, questions regarding clinical gout manifestations were included with an extra focus on therapy-refractory cases. Finally, G.P.'s were asked to rate the current care status of gout. RESULTS: Data from 4016 gout patients (age at diagnosis: 62.8 years, IQR 55 - 67.8) were collected. The majority of patients were male (75 %) with podagra being the most common gout manifestation (85 %). Chronic tophaceous courses were reported in 15 % (median 10 %, IQR 2 - 20) and spinal involvement in 2.7 % (median 0 %, IQR 0 - 2) of patients respectively. An average of 11.3 % cases (median 10 %, IQR 2.3 - 20) were defined as "hard-to-treat". However, biologic agents were not namely reported as applied treatments. 32 % of patients were diagnosed with gout by their G.P., whereas 68 % had to visit further physicians. A definite diagnosis could be reached after 3.1 months on average (median 0.3, IQR 0.1 - 1). CONCLUSIONS: In the era of biologic therapies there is a need for optimization of gout management. Important targets are the shortening of diagnostic periods and the prevention of chronic disease courses. Critical awareness of the disease and its comorbidities, standardized treatment and patient-training could be important steps toward this direction.


Assuntos
Medicina Geral/métodos , Gota/epidemiologia , Gota/terapia , Idoso , Artrite Gotosa/diagnóstico , Artrite Gotosa/epidemiologia , Artrite Gotosa/terapia , Comorbidade , Feminino , Medicina Geral/estatística & dados numéricos , Alemanha/epidemiologia , Gota/complicações , Gota/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Educação de Pacientes como Assunto , Encaminhamento e Consulta/estatística & dados numéricos , Insuficiência Renal/complicações , Fatores de Risco , Inquéritos e Questionários , Fatores de Tempo
12.
Eur J Cancer Care (Engl) ; 28(4): e13056, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31016812

RESUMO

This study investigated how doctors communicate the uncertainties of survival prognoses to patients recently diagnosed with life-threatening cancer, and suggests ways to improve this communication. Two hundred thirty-eight Norwegian oncologists and general practitioners (GPs) participated in Study 1. The study included both a scenario and a survey. The scenario asked participants to respond to a hypothetical patient who wanted to know how long (s)he could be expected to live. There were marked differences in responses within both groups, but few differences between the GPs and oncologists. There was a strong reluctance among doctors to provide patients with a prognosis. Even when they were presented with a statistically well-founded right-skewed survival curve, only a small minority provided hope by communicating the variation in survival time. In Study 2, 177 healthy students rated their preferences for different ways of receiving information regarding the uncertainty of a survival prognosis. Participants who received an explicitly described right-skewed survival curve believed that they would feel more hopeful. These participants also obtained a more realistic understanding of the variation in survival than those who did not receive this information. Based on the findings of the two studies and on extant psychological research, the author suggests much-needed guidelines for communicating survival prognoses in a realistic and optimistic way to patients recently diagnosed with life-threatening cancer. In particular, the guidelines emphasise that the doctor explains the often strongly right-skewed variation in survival time, and thereby providing the patient with realistic hope.


Assuntos
Neoplasias/psicologia , Educação de Pacientes como Assunto/métodos , Incerteza , Adulto , Sobreviventes de Câncer/psicologia , Comunicação , Feminino , Medicina Geral/métodos , Medicina Geral/normas , Clínicos Gerais/normas , Esperança , Humanos , Masculino , Oncologia/normas , Pessoa de Meia-Idade , Noruega , Oncologistas/normas , Relações Médico-Paciente , Prática Profissional/normas , Prognóstico , Estudos Prospectivos
13.
Br J Gen Pract ; 69(682): e314-e320, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30962224

RESUMO

BACKGROUND: Physiotherapists are currently working in primary care as first contact practitioners (FCP), assessing and managing patients with musculoskeletal conditions instead of GPs. There are no published data on these types of services. AIM: To evaluate a new service presenting the first 2 years of data. DESIGN AND SETTING: Analysis of 2 years' data of patient outcomes and a patient experience questionnaire from two GP practices in Forth Valley NHS, UK. The service was launched in November 2015 in response to GP shortages. METHOD: Data were collected from every patient contact in the first 2 years. This included outcomes of appointments, GP support, capacity of the service, referral rates to physiotherapy and orthopaedics, numbers of steroid injections, and outcomes from orthopaedic referrals. A patient experience questionnaire was also conducted. RESULTS: A total of 8417 patient contacts were made, with the majority managed within primary care (n = 7348; 87.3%) and 60.4% (n = 5083) requiring self-management alone. Referrals to orthopaedics were substantially reduced in both practices. Practice A from 1.1 to 0.7 per 1000 patients; practice B from 2.4 to 0.8 per 1000 patients. Of referrals to orthopaedics, 86% were considered 'appropriate'. Extended scope physiotherapists (ESPs) asked for a GP review in 1% of patients. CONCLUSION: The results suggest that patients with musculoskeletal conditions may be assessed and managed independently and effectively by physiotherapists instead of GPs. This has the potential to significantly reduce workload for GPs as the service requires minimal GP support. The majority of patients were managed within primary care, with low referral rates and highly appropriate referrals to orthopaedics. Patients reported positive views regarding the service.


Assuntos
Medicina Geral , Doenças Musculoesqueléticas , Fisioterapeutas/normas , Qualidade da Assistência à Saúde , Encaminhamento e Consulta/organização & administração , Medicina Geral/métodos , Medicina Geral/organização & administração , Humanos , Doenças Musculoesqueléticas/diagnóstico , Doenças Musculoesqueléticas/terapia , Satisfação do Paciente , Reino Unido
14.
Aust J Prim Health ; 25(2): 152-156, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30955507

RESUMO

Physical activity is an important component of standard care to ensure quality of life for prostate cancer survivors. This paper describes the frequency of physical activity management (physical activity counselling or referrals) by GPs for prostate cancer survivors. A secondary aim is to explore GP characteristics that may influence physical activity recommendations, such as GP or patient age, GP gender and GP geographical location. Analysis was conducted using the longitudinal survey data from the Bettering the Care and Evaluation of Health (BEACH) study. Consultations where prostate cancer was managed, but not classified as a new problem or associated with palliative care, were included. GPs provided physical activity recommendations at 2.0% (n = 58/2882) of prostate cancer survivorship management contacts. The physical activity management provided was physical activity counselling on 39 occasions and a physical activity referral on 19 occasions. All physical activity referrals were made to physiotherapy. After controlling for potential confounding factors, results showed that younger GPs used physical activity management at four-fold the rate of older GPs, and that GPs in major cities used physical activity management at twice the rate of rural GPs. No patient characteristics influenced physical activity management. Australian GPs rarely incorporate physical activity management as part of their management of prostate cancer. Strategies are needed to increase the frequency with which GPs recommend physical activity for prostate cancer survivors.


Assuntos
Aconselhamento/estatística & dados numéricos , Exercício , Medicina Geral/métodos , Padrões de Prática Médica/estatística & dados numéricos , Neoplasias da Próstata/reabilitação , Encaminhamento e Consulta/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Austrália , Sobreviventes de Câncer , Clínicos Gerais , Humanos , Masculino , Pessoa de Meia-Idade
17.
Hypertension ; 73(6): 1240-1248, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31006331

RESUMO

We developed an innovative automated home blood pressure (BP) monitoring method that measures BP while asleep repeatedly over several days. Our aim was to assess the predictive ability of nighttime BP obtained using the home BP device for incident cardiovascular disease (CVD) in general practice patients. We used data from the nationwide practice-based J-HOP (Japan Morning Surge-Home Blood Pressure) Nocturnal BP Study, which recruited 2545 Japanese with a history of or risk factors for CVD (mean age 63 years; antihypertensive medication use 83%). The associations between nighttime home BPs (measured at 2:00, 3:00, and 4:00 am using validated, automatic, and oscillometric home BP devices) and incident CVD, including coronary disease and stroke events, were assessed with Cox proportional hazards models. The mean±SD office, morning home, and nighttime home systolic BP (SBP)/diastolic BP were 140±15/82±10, 137±15/79±10, and 121±15/70±9 mm Hg, respectively. During a follow-up of 7.1±3.8 years (18,116 person-years), 152 CVD events occurred. A 10-mm Hg increase of nighttime home SBP was associated with an increased risk of CVD events (hazard ratios [95% CIs]: 1.201 [1.046-1.378]), after adjustments for covariates including office and morning home SBPs. The model fit assessed by the change in Goodness-of-Fit was improved when we added nighttime home SBP into the base models including office and morning home SBPs (Δ6.838 [5.6%]; P=0.009). This is among the first and largest nationwide practice-based study demonstrating that nighttime SBP obtained using a home device is a predictor of incident CVD events, independent of in-office and morning in-home SBP measurement. Clinical Trial Registration- URL: http://www.umin.ac.jp/icdr/index.html . Unique identifier: UMIN000000894.


Assuntos
Monitorização Ambulatorial da Pressão Arterial/métodos , Pressão Sanguínea/fisiologia , Doenças Cardiovasculares/fisiopatologia , Ritmo Circadiano , Medicina Geral/métodos , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Feminino , Seguimentos , Humanos , Incidência , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Sístole , Fatores de Tempo
18.
Br J Gen Pract ; 69(682): e345-e355, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31015221

RESUMO

BACKGROUND: Medication errors frequently occur as patients transition between hospital and the community, and may result in patient harm. Novel methods are required to address this issue. AIM: To assess the feasibility of introducing an electronic patient-held active record of medication status device (PHARMS) at the primary-secondary care interface at the time of hospital discharge. DESIGN AND SETTING: A mixed-methods study (non-randomised controlled intervention, and a process evaluation of qualitative interviews and non-participant observation) among patients >60 years in an urban hospital and general practices in Cork, Ireland. METHOD: The number and clinical significance of errors were compared between discharge prescriptions of the intervention (issued with a PHARMS device) and control (usual care, handwritten discharge prescription) groups. Semi-structured interviews were conducted with patients, junior doctors, GPs, and IT professionals, in addition to direct observation of the implementation process. RESULTS: In all, 102 patients were included in the final analysis (intervention n = 41, control n = 61). Total error number was lower in the intervention group (median 1, interquartile range [IQR] 0-3) than in the control group (median 8, IQR (4-13.5, P<0.001), with the clinical significance score in the intervention group also being lower than the control group (median 2, IQR 0-4 versus median 11, IQR 5-20, P<0.001). The PHARMS device was found to be technically implementable using existing information technology infrastructure, and acceptable to all key stakeholders. CONCLUSION: The results suggest that using PHARMS devices within existing systems in general practice and hospitals is feasible and acceptable to both patients and doctors, and may reduce medication error.


Assuntos
Continuidade da Assistência ao Paciente , Registros Eletrônicos de Saúde/normas , Medicina Geral , Erros de Medicação/prevenção & controle , Conduta do Tratamento Medicamentoso/organização & administração , Continuidade da Assistência ao Paciente/organização & administração , Continuidade da Assistência ao Paciente/normas , Estudos de Viabilidade , Feminino , Grupos Focais , Medicina Geral/métodos , Medicina Geral/organização & administração , Humanos , Irlanda , Masculino , Pessoa de Meia-Idade , Alta do Paciente/normas
19.
Rev Epidemiol Sante Publique ; 67(3): 169-174, 2019 May.
Artigo em Francês | MEDLINE | ID: mdl-30853146

RESUMO

INTRODUCTION: Frailty is a complex concept that can be assessed with multiple instruments. Its assessment has often been implemented in hospitals. However, first-line prevention of the frailty syndrome is paramount in general medicine. The aim of the study was to test the feasibility and the concordance of two instruments for assessing frailty and to test the adequacy between the level of frailty and the presence of caregivers. METHODS: We conducted a descriptive, analytical cross-sectional study in Reims during two months. Patients included were 65 and older. Second consultations were not retained. We collected the patients' the SEGA and Fried scores as well as the opinions of the doctor and the resident student on the presence of frailty and the presence or not of home-help. RESULTS: There was an excellent concurrence between the doctor's assessment and the SEGA score (Kappa=0.89) and a moderate concurrence with the Fried score (Kappa=0.46) compared to 0.95 and 0.50 respectively for the resident student's assessment. The agreement between the assessments of the resident student and the doctor was excellent (Kappa=0.95) the concurrence between frailty and the home-helpers showed that when patients displayed frailty symptoms home-helpers were absent in 69.6% of the cases, but planned in 82.6%. CONCLUSION: To conclude, in general medicine, there is no reference score for fraily assessment, whereas the SEGA score is easy to use and reproducible. It can be used as a score of reference for patient assessment and monitoring.


Assuntos
Fragilidade/diagnóstico , Medicina Geral/normas , Avaliação Geriátrica/métodos , Geriatria/normas , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Estudos de Viabilidade , Feminino , Idoso Fragilizado/estatística & dados numéricos , Fragilidade/epidemiologia , França/epidemiologia , Medicina Geral/métodos , Medicina Geral/estatística & dados numéricos , Geriatria/métodos , Geriatria/estatística & dados numéricos , Humanos , Masculino , Padrões de Referência
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