Cultural adaptation and psychometric evaluation of the Kinyarwanda version of the diabetes-39 (D-39) questionnaire.

BACKGROUND: In recent years, more importance is being given to the assessment of quality of life (QoL) among diabetic patients as a measure of their health and the goal of all health interventions. Other studies have reported a high prevalence of diabetes-related effects on; however, there is a knowledge gap in the region of Sub-Saharan Africa, as is the case for Rwanda, where the prevalence of diabetes is expected to rise over the next decade. The aim of this study is to report on the translation and cultural adaptation of the Diabetes-39 (D-39) questionnaire into the Kinyarwanda and its psychometric properties among diabetic patients in Rwanda. METHODS: The D-39 questionnaire-a five-scale, disease-specific QoL questionnaire-was translated from English to Kinyarwanda, then back-translated to English. A consensus meeting discussed discrepancies and agreed on changes. Interviews were conducted with 26 participants before producing a final version. For the psychometric evaluation, the adapted version was administered to 309 patients with diabetes mellitus. Participants either came from a separate cluster-randomised controlled trial or were recruited ad hoc for this study. The evaluation included testing internal consistency, known group validity, and construct validity. RESULTS: Participants' mean age was 51 ± 12.7 years with a predominance of women (64%) in the sample. All five scales of the questionnaire showed a good internal consistency, with composite reliability of above 0.7. The five-factor model of the questionnaire was fitted to the 39 items. Although the fit was not exact, there was a satisfactory approximate fit (CFI = 0.93, TLI = 0.92, RMSEA = 0.05). There was a good discriminant validity except for the "social burden" and "anxiety and worry" scales (inter-factor correlation = 0.80). CONCLUSIONS: Diabetes-39 is a questionnaire developed in English that was adapted and translated into Kinyarwanda. The Kinyarwanda version of D-39 is a reliable and valid instrument to measure QoL among diabetic patients in Rwanda. The questionnaire can be helpful in research and clinical practice improving health outcomes for patients with diabetes in Rwanda and other Kinyarwanda-competent areas in the sub-region. However, certain cross-cultural differences should be considered.

Cultural adaptation and psychometric evaluation of the Kinyarwanda version of the problem areas in diabetes (PAID) questionnaire.

BACKGROUND: High prevalence rates in diabetes-related distress have been observed in several studies; however, in the region of Sub-Saharan Africa evidence is lacking as is, for example, the case for Rwanda, where diabetes prevalence is expected to increase over the next decade. The aim of this study is to report on the translation and cultural adaption of the problem areas in diabetes (PAID) questionnaire into Kinyarwanda and its psychometric properties. METHODS: The questionnaire was translated following a standard procedure. Interviews were conducted with 29 participants before producing a final version. For the psychometric evaluation, a sample of 266 patients with diabetes mellitus, aged 21-64 years old were examined. Participants either came from a separate cluster-randomised controlled trial or were recruited ad-hoc for this study. The evaluation included testing internal consistency, known groups validity, and construct validity. A series of confirmatory factor analysis were conducted investigating seven previously established factorial structures. An exploratory factor analysis (EFA) was also carried out to examine the structure further. RESULTS: The full scale showed good internal reliability (Cronbach's α = 0.88). A four-factor solution previously tested in Spain with subdimensions of emotional, treatment, food-related and social-support problems demonstrated adequate approximate fit (RMSEA = 0.056; CFI = 0.951; TLI = 0.943). The EFA revealed a four-factor structure; however, two of these factors were not as homogeneous and easily interpretable as those of the Spanish model. CONCLUSIONS: The psychometric properties of the Kinyarwanda version of PAID are acceptable. The questionnaire can be helpful in research and clinical practice in Rwanda, however certain cross-cultural differences should be taken into account.

Say it in Croatian--Croatian translation of the EGPRN definition of multimorbidity using a Delphi consensus technique.

Patients coming to their family physician (FP) usually have more than one condition or problem. Multimorbidity as well as dealing with it, is challenging for FPs even as a mere concept. The World Health Organization (WHO) has simply defined multimorbidity as two or more chronic conditions existing in one patient. However, this definition seems inadequate for a holistic approach to patient care within Family Medicine. Using systematic literature review the European General Practitioners Research Network (EGPRN) developed a comprehensive definition of multimorbidity. For practical and wider use, this definition had to be translated into other languages, including Croatian. Here presented is the Croatian translation of this comprehensive definition using a Delphi consensus procedure for forward/backward translation. 23 expert FPs fluent in English were asked to rank the translation from 1 (absolutely disagreeable) to 9 (fully agreeable) and to explain each score under 7. It was previously defined that consensus would be reached when 70% of the scores are above 6. Finally, a backward translation from Croatian into English was undertaken and approved by the authors of the English definition. Consensus was reached after the first Delphi round with 100% of the scores above 6; therefore the Croatian translation was immediately accepted. The authors of the English definition accepted the backward translation. A comprehensive definition of multimorbidity is now available in English and Croatian, as well as other European languages which will surely make further implications for clinicians, researchers or policy makers.

Exploring the accessibility of primary health care data in Europe's COVID-19 response: developing key indicators for managing future pandemics (Eurodata study).

BACKGROUND: Primary Health Care (PHC) plays a crucial role in managing the COVID-19 pandemic, with only 8% of cases requiring hospitalization. However, PHC COVID-19 data often goes unnoticed on European government dashboards and in media discussions. This project aims to examine official information on PHC patient care during the COVID-19 pandemic in Europe, with specific objectives: (1) Describe PHC's clinical pathways for acute COVID-19 cases, including long-term care facilities, (2) Describe PHC COVID-19 pandemic indicators, (3) Develop COVID-19 PHC activity indicators, (4) Explain PHC's role in vaccination strategies, and (5) Create a PHC contingency plan for future pandemics. METHODS: A mixed-method study will employ two online questionnaires to gather retrospective PHC data on COVID-19 management and PHC involvement in vaccination strategies. Validation will occur through focus group discussions with medical and public health (PH) experts. A two-wave Delphi survey will establish a European PHC indicators dashboard for future pandemics. Additionally, a coordinated health system action plan involving PHC, secondary care, and PH will be devised to address future pandemic scenarios. ANALYSIS: Quantitative data will be analysed using STATA v16.0 for descriptive and multivariate analyses. Qualitative data will be collected through peer-reviewed questionnaires and content analysis of focus group discussions. A Delphi survey and multiple focus groups will be employed to achieve consensus on PHC indicators and a common European health system response plan for future pandemics. The Eurodata research group involving researchers from 28 European countries support the development. DISCUSSION: While PHC manages most COVID-19 acute cases, data remains limited in many European countries. This study collects data from numerous countries, offering a comprehensive perspective on PHC's role during the pandemic in Europe. It pioneers the development of a PHC dashboard and health system plan for pandemics in Europe. These results may prove invaluable in future pandemics. However, data may have biases due to key informants' involvement and may not fully represent all European GP practices. PHC has a significant role in the management of the COVID-19 pandemic, as most of the cases are mild or moderate and only 8% needed hospitalization. However, PHC COVID-19 activity data is invisible on governments' daily dashboards in Europe, often overlooked in media and public debates.

Lower gastric sensitivity in quiescent inflammatory bowel disease than in irritable bowel syndrome.

OBJECTIVE: Visceral hypersensitivity is considered a key symptom in inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS), both of which seriously affect health-related quality of life (HrQoL). Previous findings are mostly based on invasive procedures that may interfere with the assessment of visceral perception. The current study, therefore, investigates whether IBD and IBS are characterized by altered perception of 'natural' gastric distensions ('interoception'). METHODS: Twenty IBD patients in remission (13 Crohn's disease, 7 ulcerative colitis), 12 IBS patients, and 20/12 matched healthy control (HC) individuals, respectively, underwent the water load test, in which they could drink ad libitum until the subjective thresholds of satiation (stage 1) and fullness (stage 2) were reached. Gastric motility was assessed using electrogastrography. RESULTS: IBD patients drank significantly more water until satiation than IBS patients, whereas no differences between patients and HC groups were observed. Electrogastrographic patterns were comparable between groups, suggesting no pathologies in gastric motility in IBD or IBS. The amount of water consumed until satiation negatively correlated with HrQoL related to bowel symptoms in IBD patients, but was positively associated with emotional well-being in IBS patients. CONCLUSION: Our findings implicate relative gastric hypersensitivity in IBS, and relative hyposensitivity in IBD patients, which are both related to specific HrQoL aspects.

Quality of life among adult patients living with diabetes in Rwanda: a cross-sectional study in outpatient clinics.

OBJECTIVES: To report on the disease-related quality of life of patients living with diabetes mellitus in Rwanda and identify its predictors. DESIGN: Cross-sectional study, part of the baseline assessment of a cluster-randomised controlled trial. SETTING: Outpatient clinics for non-communicable diseases of nine hospitals across Rwanda. PARTICIPANTS: Between January and August 2019, 206 patients were recruited as part of the clinical trial. Eligible participants were those aged 21-80 years and with a diagnosis of diabetes mellitus for at least 6 months. Illiterate patients, those with severe hearing or visual impairments, those with severe mental health conditions, terminally ill, and those pregnant or in the postpartum period were excluded PRIMARY AND SECONDARY OUTCOME MEASURES: Disease-specific quality of life was measured with the Kinyarwanda version of the Diabetes-39 (D-39) questionnaire. A glycated haemoglobin (HbA1c) test was performed on all patients. Sociodemographic and clinical data were collected, including medical history, disease-related complications and comorbidities. RESULTS: The worst affected dimensions of the D-39 were 'anxiety and worry' (mean=51.63, SD=25.51), 'sexual functioning' (mean=44.58, SD=37.02), and 'energy and mobility' (mean=42.71, SD=20.69). Duration of the disease and HbA1c values were not correlated with any of the D-39 dimensions. A moderating effect was identified between use of insulin and achieving a target HbA1c of 7% in the 'diabetes control' scale. The most frequent comorbidity was hypertension (49.0% of participants), which had a greater negative effect on the 'diabetes control' and 'social burden' scales in women. Higher education was a predictor of less impact on the 'social burden' and 'energy and mobility' scales. CONCLUSIONS: Several variables were identified as predictors for the five dimensions of quality of life that were studied, providing opportunities for tailored preventive programmes. Further prospective studies are needed to determine causal relationships. TRIAL REGISTRATION NUMBER: NCT03376607.

A web-based versus paper questionnaire on alcohol and tobacco in adolescents.

OBJECTIVE: Our study was aimed at comparing health behavior data collected from a Web-based self-administered questionnaire (Web SAQ) versus a paper-and-pencil self-administered questionnaire and assessing the feasibility of the application. MATERIALS AND METHODS: One hundred and ninety (n = 190) pupils (ages 14-16 years) of senior high schools anonymously completed a questionnaire, with demographics and queries about lifestyle, alcohol, and tobacco use. For each class, the adolescents were randomly assigned to complete either the paper version of the questionnaire or the equivalent Web-based one, which used a customized platform developed for the purposes of this survey. RESULTS: Females who filled out the Web SAQ required significantly less time and completed a significantly higher percentage of its items. Although the majority of questions on tobacco and alcohol did not differ significantly across the two administration modes, there were gender-related differences in some sensitive information. Male adolescents on the Web SAQ accounted higher per hour drink consumption (r = 0.27, p = 0.015) and more numerous episodes of inebriety (r = 0.26, p = 0.010), whereas females seemed to state a younger age of alcohol onset (r = 0.33, p = 0.002). Females were more likely to report being monthly smokers on the Web SAQ (odds ratio = 0.37). Adolescents felt significantly less observed and females referred being more independent while compiling the Web SAQ. CONCLUSIONS: The findings of the study suggest that differences in reporting of some behavior of adolescents when using a Web SAQ do exist, despite the small-to-medium effect sizes. Exploiting the Web requires further investigation for extensive comprehension of the reasons for such differences.

Family Violence Curricula in Europe (FAVICUE): a cross-sectional descriptive study protocol.

INTRODUCTION: Family violence (FV) is a widespread public health problem of epidemic proportions and serious consequences. Doctors may be the first or only point of contact for victims who may be hesitant or unable to seek other sources of assistance, and they tend not to disclose abuse to doctors if not specifically asked. A comprehensive healthcare response is key to a coordinated community-wide approach to FV, but most of the practising physicians have received either no or insufficient education or training in any aspect of FV. Training of medical students concerning FV is often delivered in an inconsistent or ad hoc manner.The main aim of this project, Family Violence Curricula in Europe (FAVICUE), is to (1) describe current FV education delivery in European medical universities (undergraduate period) and during the specialist training in general practice (GP)/family medicine (FM) (postgraduate residency programme), and (2) compare it with WHO recommendations for FV curriculum. METHODS AND ANALYSIS: This is the protocol of a cross-sectional descriptive study consisting of two self-report online surveys (for undergraduate and postgraduate training, respectively) with 40 questions each. For both surveys, general practitioners, residents, medical students and professionals involved in their education from countries of the European region will be identified through the European Regional Branch of the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA Europe) and will be invited to provide information regarding the training on FV. Descriptive tests will be carried out and a thematic analysis will be conducted on the open-ended questions. ETHICS AND DISSEMINATION: Ethics approval has been obtained by the University of Luxembourg (ERP 17-015 FAVICUE). The results will provide important information concerning current curricula on FV, and can be used for mapping the educational needs and planning the implementation of future training interventions. They will be published and disseminated through WONCA Europe and its networks.

Community- and mHealth-based integrated management of diabetes in primary healthcare in Rwanda (D²Rwanda): the protocol of a mixed-methods study including a cluster randomised controlled trial.

INTRODUCTION: In Rwanda, diabetes mellitus prevalence is estimated between 3.1% and 4.3%. To address non-communicable diseases and the shortage of health workforce, the Rwandan Ministry of Health has introduced the home-based care practitioners (HBCPs) programme: laypeople provide longitudinal care to chronic patients after receiving a six-month training. Leveraging technological mobile solutions may also help improve health and healthcare. The D²Rwanda study aims at: (a) determining the efficacy of an integrated programme for the management of diabetes in Rwanda, which will provide monthly patient assessments by HBCPs, and an educational and self-management mHealth patient tool, and; (b) exploring qualitatively the ways the interventions will have been enacted, their challenges and effects, and changes in the patients' health behaviours and HBCPs' work satisfaction. METHODS AND ANALYSIS: This is a mixed-methods sequential explanatory study. First, there will be a one-year cluster randomised controlled trial including two interventions ((1) HBCPs' programme; (2) HBCPs' programme + mobile health application) and usual care (control). Currently, nine hospitals run the HBCPs' programme. Under each hospital, administrative areas implementing the HBCPs' programme will be randomised to receive intervention 1 or 2. Eligible patients from each area will receive the same intervention. Areas without the HBCPs' programme will be assigned to the control group. The primary outcome will be changes in glycated haemoglobin. Secondary outcomes include medication adherence, mortality, complications, health-related quality of life, diabetes-related distress and health literacy. Second, at the end of the trial, focus group discussions will be conducted with patients and HBCPs. Financial support was received from the Karen Elise Jensens Fond, and the Universities of Aarhus and Luxembourg. ETHICS AND DISSEMINATION: Ethics approval was obtained from the Rwanda National Ethics Committee and the Ethics Review Panel of the University of Luxembourg. Findings will be disseminated via peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT03376607; Pre-results.

Combating non-communicable diseases: potentials and challenges for community health workers in a digital age, a narrative review of the literature.

The use of community health workers (CHWs) has been explored as a viable option to provide home health education, counselling and basic health care, notwithstanding their challenges in training and retention. In this manuscript, we review the evidence and discuss how the digitalization affects the CHWs programmes for tackling non-communicable diseases (NCDs) in low- and middle-income countries (LMICs). We conducted a review of literature covering two databases: PubMED and Embase. A total of 97 articles were abstracted for full text review of which 26 are included in the analysis. Existing theories were used to construct a conceptual framework for understanding how digitalization affects the prospects of CHW programmes for NCDs. The results are divided into two themes: (1) the benefits of digitalization and (2) the challenges to the prospects of digitalization. We also conducted supplemental search in non-peer reviewed literature to identify and map the digital platforms currently in use in CHW programmes. We identified three benefits and three challenges of digitalization. Firstly, it will help improve the access and quality of services, notwithstanding its higher establishment and maintenance costs. Secondly, it will add efficiency in training and personnel management. Thirdly, it will leverage the use of data generated across grass-roots platforms to further research and evaluation. The challenges posed are related to funding, health literacy of CHWs and systemic challenges related to motivating CHWs. Several dozens of digital platforms were mapped, including mobile-based networking devices (used for behavioural change communication), Web-applications (used for contact tracking, reminder system, adherence tracing, data collection and decision support), videoconference (used for decision support) and mobile applications (used for reminder system, supervision, patients' management, hearing screening and tele-consultation). The digitalization efforts of CHW programmes are afflicted by many challenges, yet the rapid technological penetration and acceptability coupled with the gradual fall in costs constitute encouraging signals for the LMICs. Both CHWs interventions and digital technologies are not inexpensive, but they may provide better value for the money when applied at the right place and time.

Randomised controlled non-inferiority trial of primary care-based facilitated access to an alcohol reduction website.

BACKGROUND: Brief interventions (BIs) delivered in primary care have been shown to be effective in reducing risky drinking, but implementation is limited. Facilitated access to a digital application offers a novel alternative to face-to-face intervention, but its relative effectiveness is unknown. METHODS: Primary care-based, non-inferiority, randomised controlled trial comparing general practitioner (GP) facilitated access to an interactive alcohol reduction website (FA) with face-to-face BI for risky drinking. Patients screening positive on the short Alcohol Use Disorders Identification Test (AUDIT-C) were invited to participate in the trial. Assessment at baseline, 3 months and 12 months was carried out using AUDIT and EQ-5D-5L questionnaires. FINDINGS: 58 participating GPs approached 9080 patients of whom 4529 (49.9%) logged on, 3841 (84.8%) undertook screening, 822 (21.4%) screened positive and 763 (19·9%) were recruited. 347 (45.5%) were allocated to FA and 416 (54.5%) to BI. At 3 months, subjects in FA group with an AUDIT score of ≥8 reduced from 95 (27.5%) to 85 (26.8%) while those in BI group increased from 123 (20.6%) to 141 (37%). Differences between groups were principally due to responses to AUDIT question 10. Analysis of primary outcome indicated non-inferiority of FA compared with BI, and prespecified subgroup analysis indicated benefits for older patients and those with higher levels of computer literacy and lower baseline severity. Additional analyses undertaken to take account of bias in response to AUDIT question 10 failed to support non-inferiority within the prespecified 10% boundary. INTERPRETATION: Prespecified protocol-driven analyses of the trial indicate that FA is non-inferior to BI; however, identified bias in the outcome measure and further supportive analyses question the robustness of this finding. It is therefore not possible to draw firm conclusions from this trial, and further research is needed to determine whether the findings can be replicated using more robust outcome measures. TRIAL REGISTRATION NUMBER: NCT01638338; Results.

Randomised controlled non-inferiority trial of primary care-based facilitated access to an alcohol reduction website: cost-effectiveness analysis.

OBJECTIVES: To evaluate the 12-month costs and quality-adjusted life years (QALYs) gained to the Italian National Health Service of facilitated access to a website for hazardous drinkers compared with a standard face-to-face brief intervention (BI). DESIGN: Randomised 1:1 non-inferiority trial. SETTING: Practices of 58 general practitioners (GPs) in Italy. PARTICIPANTS: Of 9080 patients (>18 years old) approached to take part in the trial, 4529 (49·9%) logged on to the website and 3841 (84.8%) undertook online screening for hazardous drinking. 822 (21.4%) screened positive and 763 (19.9%) were recruited to the trial. INTERVENTIONS: Patients were randomised to receive either a face-to-face BI or access via a brochure from their GP to an alcohol reduction website (facilitated access). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome is the cost per QALY gained of facilitated access compared with face-to-face. A secondary analysis includes total costs and benefits per 100 patients, including number of hazardous drinkers prevented at 12 months. RESULTS: The average time required for the face-to-face BI was 8 min (95% CI 7.5 min to 8.6 min). Given the maximum time taken for facilitated access of 5 min, face-to-face is an additional 3 min: equivalent to having time for another GP appointment for every three patients referred to the website. Complete case analysis adjusting for baseline the difference in QALYs for facilitated access is 0.002 QALYs per patient (95% CI -0.007 to 0.011). CONCLUSIONS: Facilitated access to a website to reduce hazardous drinking costs less than a face-to-face BI given by a GP with no worse outcomes. The lower cost of facilitated access, particularly in regards to investment of time, may facilitate the increase in provision of BIs for hazardous drinking. TRIAL REGISTRATION NUMBER: NCT01638338;Post-results.

Download Your Doctor: Implementation of a Digitally Mediated Personal Physician Presence to Enhance Patient Engagement With a Health-Promoting Internet Application.

BACKGROUND: Brief interventions delivered in primary health care are effective in reducing excessive drinking; online behavior-changing technique interventions may be helpful. Physicians may actively encourage the use of such interventions by helping patients access selected websites (a process known as "facilitated access"). Although the therapeutic working alliance plays a significant role in the achievement of positive outcomes in face-to-face psychotherapy and its development has been shown to be feasible online, little research has been done on its impact on brief interventions. Strengthening patients' perception of their physician's endorsement of a website could facilitate the development of an effective alliance between the patient and the app. OBJECTIVE: We describe the implementation of a digitally mediated personal physician presence to enhance patient engagement with an alcohol-reduction website as part of the experimental online intervention in a noninferiority randomized controlled trial. We also report the feedback of the users on the module. METHODS: The Download Your Doctor module was created to simulate the personal physician presence for an alcohol-reduction website that was developed for the EFAR-FVG trial conducted in the Italian region of Friuli-Venezia-Giulia. The module was designed to enhance therapeutic alliance and thus improve outcomes in the intervention group (facilitated access to the website). Participating general and family practitioners could customize messages and visual elements and upload a personal photo, signature, and video recordings. To assess the perceptions and attitudes of the physicians, a semistructured interview was carried out 3 months after the start of the trial. Participating patients were invited to respond to a short online questionnaire 12 months following recruitment to investigate their evaluation of their online experiences. RESULTS: Nearly three-quarters (23/32, 72%) of the physicians interviewed chose to customize the contents of the interaction with their patients using the provided features and acknowledged the ease of use of the online tools. The majority of physicians (21/32, 57%) customized at least the introductory photo and video. Barriers to usage among those who did not customize the contents were time restrictions, privacy concerns, difficulties in using the tools, and considering the approach not useful. Over half (341/620, 55.0%) of participating patients completed the optional questionnaire. Many of them (240/341, 70.4%) recalled having noticed the personalized elements of their physicians, and the majority of those (208/240, 86.7%) reacted positively, considering the personalization to be of either high or the highest importance. CONCLUSIONS: The use of a digitally mediated personal physician presence online was both feasible and welcomed by both patients and physicians. Training of the physicians seems to be a key factor in addressing perceived barriers to usage. Further research is recommended to study the mechanisms behind this approach and its impact. TRIAL REGISTRATION: Clinicaltrials.gov NCT 01638338; https://clinicaltrials.gov/ct2/show/NCT01638338 (Archived by WebCite at http://www.webcitation.org/6f0JLZMtq).

How do general practitioners recognize the definition of multimorbidity? A European qualitative study.

BACKGROUND: Multimorbidity is a challenging concept for general practice. An EGPRN working group has published a comprehensive definition of the concept of multimorbidity. As multimorbidity could be a way to explore complexity in general practice, it was of importance to explore whether European general practitioners (GPs) recognize this concept and whether they would change it. OBJECTIVES: To investigate whether European GPs recognize the EGPRN concept of multimorbidity and whether they would change it. METHODS: Focus group meetings and semi-structured interviews as data collection techniques with a purposive sample of practicing GPs from every country. Data collection continued until saturation was reached in every country. The analysis was undertaken using a grounded theory based method. In each national team, four independent researchers, working blind and pooling data, carried out the analysis. To ensure the internationalization of the data, an international team of 10 researchers pooled the axial and selective coding of all national teams to check the concept and highlight emerging themes. RESULTS: The maximal variation and saturation of the sample were reached in all countries with 211 selected GPs. The EGPRN definition was recognized in all countries. Two additional ideas emerged, the use of Wonca's core competencies of general practice, and the dynamics of the doctor-patient relationship for detecting and managing multimorbidity and patient's complexity. CONCLUSION: European GPs recognized and enhanced the EGPRN concept of multimorbidity. These results open new perspectives regarding the management of complexity using the concept of multimorbidity in general practice. [Box: see text].

The European general practice research network presents the translations of its comprehensive definition of multimorbidity in family medicine in ten European languages.

BACKGROUND: Multimorbidity, according to the World Health Organization, exists when there are two or more chronic conditions in one patient. This definition seems inaccurate for the holistic approach to Family Medicine (FM) and long-term care. To avoid this pitfall the European General Practitioners Research Network (EGPRN) designed a comprehensive definition of multimorbidity using a systematic literature review. OBJECTIVE: To translate that English definition into European languages and to validate the semantic, conceptual and cultural homogeneity of the translations for further research. METHOD: Forward translation of the EGPRN's definition of multimorbidity followed by a Delphi consensus procedure assessment, a backward translation and a cultural check with all teams to ensure the homogeneity of the translations in their national context. Consensus was defined as 70% of the scores being higher than 6. Delphi rounds were repeated in each country until a consensus was reached. RESULTS: 229 European medical expert FPs participated in the study. Ten consensual translations of the EGPRN comprehensive definition of multimorbidity were achieved. CONCLUSION: A comprehensive definition of multimorbidity is now available in English and ten European languages for further collaborative research in FM and long-term care.

A randomised controlled non-inferiority trial of primary care-based facilitated access to an alcohol reduction website (EFAR-FVG): the study protocol.

INTRODUCTION: There is a strong body of evidence demonstrating the effectiveness of brief interventions by primary care professionals for risky drinkers. However, implementation levels remain low because of time constraints and other factors. Facilitated access to an alcohol reduction website offers primary care professionals a time-saving alternative to standard face-to-face intervention, but it is not known whether it is as effective. METHODS AND ANALYSIS: A randomised controlled non-inferiority trial for risky drinkers comparing facilitated access to a dedicated website with standard face-to-face brief intervention to be conducted in primary care settings in the Region of Friuli Giulia Venezia, Italy. Adult patients will be given a leaflet inviting them to log on to a website to complete the Alcohol Use Disorders Identification Test (AUDIT-C) alcohol screening questionnaire. Screen positives will be requested to complete an online trial module including consent, baseline assessment and randomisation to either standard intervention by the practitioner or facilitated access to an alcohol reduction website. Follow-up assessment of risky drinking will be undertaken online at 1 month, 3 months and 1 year using the full AUDIT questionnaire. Proportions of risky drinkers in each group will be calculated and non-inferiority assessed against a specified margin of 10%. Assuming a reduction of 30% of risky drinkers receiving standard intervention, 1000 patients will be required to give 90% power to reject the null hypothesis. ETHICS AND DISSEMINATION: The protocol was approved by the Isontina Independent Local Ethics Committee on 14 June 2012. The findings of the trial will be disseminated through peer-reviewed journals, national and international conference presentations and public events involving the local administrations of the towns where the trial participants are resident. REGISTRATION DETAILS: Trial registration number NCT: 01638338.

The European General Practice Research Network presents a comprehensive definition of multimorbidity in family medicine and long term care, following a systematic review of relevant literature.

BACKGROUND: Multimorbidity is a new concept encompassing all the medical conditions of an individual patient. The concept links into the European definition of family medicine and its core competencies. However, the definition of multimorbidity and its subsequent operationalization are still unclear. The European General Practice Research Network wanted to produce a comprehensive definition of multimorbidity. METHOD: Systematic review of literature involving eight European General Practice Research Network national teams. The databases searched were PubMed, Embase, and Cochrane (1990-2010). Only articles containing descriptions of multimorbidity criteria were selected for inclusion. The multinational team undertook a methodic data extraction, according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. RESULTS: The team identified 416 documents, selected 68 abstracts, included 54 articles, and found 132 definitions with 1631 different criteria. These criteria were aggregated into 11 themes that led to the following definition: Multimorbidity is defined as any combination of chronic disease with at least one other disease (acute or chronic) or biopsychosocial factor (associated or not) or somatic risk factor. Any biopsychosocial factor, any risk factor, the social network, the burden of diseases, the health care consumption, and the patient's coping strategies may function as modifiers (of the effects of multimorbidity). Multimorbidity may modify the health outcomes and lead to an increased disability or a decreased quality of life or frailty. CONCLUSION: This study has produced a comprehensive definition of multimorbidity. The resulting improvements in the management of multimorbidity, and its usefulness in long term care and in family medicine, will have to be assessed in future studies.

Polonium and lung cancer.

The alpha-radioactive polonium 210 (Po-210) is one of the most powerful carcinogenic agents of tobacco smoke and is responsible for the histotype shift of lung cancer from squamous cell type to adenocarcinoma. According to several studies, the principal source of Po-210 is the fertilizers used in tobacco plants, which are rich in polyphosphates containing radio (Ra-226) and its decay products, lead 210 (Pb-210) and Po-210. Tobacco leaves accumulate Pb-210 and Po-210 through their trichomes, and Pb-210 decays into Po-210 over time. With the combustion of the cigarette smoke becomes radioactive and Pb-210 and Po-210 reach the bronchopulmonary apparatus, especially in bifurcations of segmental bronchi. In this place, combined with other agents, it will manifest its carcinogenic activity, especially in patients with compromised mucous-ciliary clearance. Various studies have confirmed that the radiological risk from Po-210 in a smoker of 20 cigarettes per day for a year is equivalent to the one deriving from 300 chest X-rays, with an autonomous oncogenic capability of 4 lung cancers per 10000 smokers. Po-210 can also be found in passive smoke, since part of Po-210 spreads in the surrounding environment during tobacco combustion. Tobacco manufacturers have been aware of the alpha-radioactivity presence in tobacco smoke since the sixties.

Is appropriate management of atrial fibrillation in primary care a utopia?

OBJECTIVE: The authors aimed at reporting on whether or not primary care doctors follow atrial fibrillation (AF) treatment protocols, and on the mental distress of such patients. METHODS: A total of 138 patients with first detected or recurrent AF were examined in a health center. Demographic data were collected and their lifestyle and medical history for rhythm-related pathologies and chronic medication were investigated. Physical examination, electrocardiogram (EKG), and in selected cases, lab analysis were carried-out. CHADS2 index was used for assessing the stroke risk in patients with AF, while the General Health Questionnaire-12 (GHQ-12) for personal health perception was performed in all patients. RESULTS: According to CHADS2 the majority of the patients had at least 1 risk factor and half of those receiving oral vitamin K antagonists presented an out-of-range international normalized ratio (INR). In 24 cases, patients used both aspirin and oral anticoagulants, while in 41 cases, medication was corrected according to index. GHQ-12 seemed to be significantly worse in paroxysmal and persistent cases, as well as in women with recurrent AF. Many paroxysmal AF patients under 75 years continued caffeine intake, whereas an extensive use of benzodiazepines was noticed in the majority of patients. CONCLUSIONS: Shortages and limitations of the peripheral or rural units and health centers and inadequate knowledge and application of the guidelines, seemed to be major factors responsible for mismanaging AF patients. More education in prehospital cardiology may contribute in improving management of arrhythmias in primary care.