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GPs' strategies in exploring the preschool child's wellbeing in the paediatric consultation

Kirsten Lykke, Pia Christensen, Susanne Reventlow

Abstract

Background: Although General Practitioners (GPs) are uniquely placed to identify children with emotional, social, and behavioural problems, they succeed in identifying only a small number of them. The aim of this article is to explore the strategies, methods, and tools employed by GPs in the assessment of the preschool child’s emotional, mental, social, and behavioural health. We look at how GPs address parental care of the child in general and in situations where GPs have a particular awareness of the child.

Method: Twenty-eight Danish GPs were purposively selected to take part in a qualitative study which combined focus-group discussions, observation of child consultations, and individual interviews with GPs.

Results: Analysis of the data suggests that GPs have developed a set of methods, and strategies to assess the preschool child and parental care of the child. They look beyond paying narrow attention to the physical health of the child and they have expanded their practice to include the relations and interactions in the consultation room. The physical examination of the child continues to play a central role in doctor-child communication.

Conclusion: The participating GPs’ strategies helped them to assess the wellbeing.

BMC Family Practice

Association between urinary markers of nucleic acid oxidation and mortality in type 2 diabetes: a population-based cohort study

Brødbæk K, Siersma V, Henriksen T, Weimann A, Petersen M, Andersen JT, Jimenez-Solem E, Hansen LJ, Henriksen JE, Bonnema SJ, de Fine Olivarius N, Poulsen HE.

Objective: We recently showed that RNA oxidation, estimated by urinary excretion of 8-oxo-7,8-dihydroguanosine (8-oxoGuo), independently predicted mortality in a cohort of 1,381 treatment-naive patients with newly diagnosed type 2 diabetes. In the present investigation, we analyzed urine collected 6 years after the diagnosis to assess the association between urinary markers of nucleic acid oxidation and mortality in patients with established and treated diabetes.

Research Design and Methods: We used data from the 970 patients who attended the screening for diabetes complications 6 years after the diagnosis. Cox proportional hazards regression was used to examine the relationship between urinary markers of DNA oxidation (8-oxo-7,8-dihydro-2'-deoxyguanosine [8-oxodG] [n = 938]) and RNA oxidation (8-oxoGuo [n = 936]) and mortality.

Results: During a median of 9.8 years of follow-up, 654 patients died. Urinary 8-oxoGuo assessed 6 years after the diagnosis was significantly associated with mortality. The multivariate-adjusted hazard ratios for all-cause and diabetes-related mortality of patients with 8-oxoGuo levels in the highest quartile compared with those in the lowest quartile were 1.86 (95% CI 1.34-2.58) and 1.72 (1.11-2.66), respectively. Conversely, 8-oxodG was not associated with mortality. In addition, we found an association between changes in 8-oxoGuo from diagnosis to 6-year follow-up and mortality, with increased risk in patients with an increase and decreased risk in patients with a decrease in 8-oxoGuo.

Conclusions: The RNA oxidation marker 8-oxoGuo is an independent predictor of mortality in patients with established and treated type 2 diabetes, and changes in 8-oxoGuo during the first 6 years after diagnosis are associated with mortality.

Diabetes Care 2013;36(3):669-76

Quality of life in children with otitits media – a cohort study

Christina T Ryborg, Jens Søndergaard, Jørgen Lous, Anders Munck, Pia V Larsen, Janus L Thomsen

Background. Studies about health-related quality of life (HRQOL) in children with otitis media have primarily focused on short-term effects of the disease, and how treatment with insertion of ventilation tubes (VTs) affects the HRQOL. More knowledge is needed about how long-term HRQOL is associated with different factors like insertion of VT and use of antibiotics.

Objective. We aimed to analyse HRQOL in children with otitis media 1 year after inclusion and to what extent insertion of VT, use of antibiotics, diagnoses, symptoms in the children, day-care attention, parental absence from work and parental smoking were associated with the long-term HRQOL in children with otitis media.

Methods. A cohort study including 397 children was carried out. The children were followed for 13 months, and symptoms, HRQOL and so on were identified by means of questionnaires.

Results. HRQOL in children with otitis media was significantly improved after 13 months. The improvement of HRQOL was significantly lower for children with sleep problems compared with children without sleep problems. The improvement in HRQOL was significantly lower in children whose parents had been absent from work during the preceding 3 months due to the child’ s otitis media compared with children with parents not being absent from their work. There were no statistically significant differences in the improvement of HRQOL in children who had received a VT during the follow-up period compared with children without a VT.

Conclusion. HRQOL in children with otitis media was significantly improved after 13 months. The improvement in HRQOL was significantly lower for children with sleep problems. The improvement in HRQOL was significantly lower in children whose parents had been absent from work due to the child’s otitis media. There were no statistically significant differences in the improvement of HRQOL in children who had received a VT during the follow-up period. 

Family Practice 2013; E-pub ahead of print 15 November

Associations between health care seeking and socioeconomic and demographic determinants among people reporting alarm symptoms of cancer: a population-based cross-sectional study

Rikke P Svendsen, Dorte E Jarbøl, Pia V Larsen, Henrik Støvring, Bjarne L Hansen, Jens Søndergaard

Background. Late diagnosis of cancer may partly be explained by the fact that some patients do not seek health care promptly when experiencing an alarm symptom. Socioeconomic and demographic differences exist concerning knowledge and awareness of cancer alarm symptoms in the general population and socioeconomic differences are found in cancer incidence and survival. We therefore hypothesise that socioeconomic and demographic differences in health care-seeking behaviour are present among people with alarm symptoms.

Objectives. To analyse associations between health care seeking and socioeconomic and demographic factors among people reporting cancer alarm symptoms.

Methods. A questionnaire survey comprising 20 000 people aged >20 from the Danish population. The questionnaire concerned alarm symptoms of common cancers and subsequent health care seeking. Data on socioeconomic factors were obtained from Statistics Denmark. Main outcomes: health care seeking and patient interval.

Results. A total of 26.1% of all subjects reported that they did not seek health care when having experienced an alarm symptom. Women—subjects aged >40, subjects living with a partner and subjects having a cancer diagnosis—were more likely to seek health care, whereas medium educational level was negatively associated with health care seeking. Further, women were more likely to seek health care within 1 month, whereas subjects out of the workforce were less likely to do so.

Conclusions. Approximately three out of four subjects sought health care when having experienced an alarm symptom but 50% waited for at least 1 month. Some demographic factors were found to be associated with health care-seeking behaviour and the patient interval, whereas no consistent associations were found with regard to socioeconomics.

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Could the patient have been seen by a nurse; a questionnaire based survey of GP and patient views in Danish general practice

Nørøxe KB, Moth G, Maindal HT, Vedsted P

Abstract

BACKGROUND: Nurses in Denmark have been increasingly involved in general practice care, which may have implications for the role of the general practitioner (GP) and patients' experience of primary care. The aim of this study was to explore possibilities of doctor-nurse substitution seen from GP and patient perspectives and patient preferences in regard to consultations with a personal GP.

METHODS: The study was based on data from a Danish survey on disease patterns in general practice (KOS 2008). Background information on patients and GPs was linked with their responses to whether a nurse could have substituted the GP in consultations and patient-assessed importance of seeing a personal GP. Associations were measured with prevalence rate ratio (PR).

RESULTS: Doctor-nurse substitution was a possibility in 14.8% of consultations according to GPs and in 11.7% according to patients. GP and patient agreed on substitution in 3.5% of consultations (Kappa = 0.164). Follow-up consultations were more often feasible for substitution than new episode according to GPs (adj. PR = 2.06 (1.62-2.62)), but not according to patients (adj. PR = 1.02 (0.64-1.33)). Follow-up consultations were related to high importance of seeing the personal GP (adj. PR = 1.18 (1.05-1.33). For both patients and GPs, consultations with patients with chronic conditions were not significantly associated with nurse substitution. Male and younger patients did more often suggest substitution than women and older patients. For GPs, increasing patient age was associated with relevance of substitution. Patients who found it 'very important' to see their personal GP were less likely to consider nurse substitution a possibility (adj. PR = 0.57 (0.45-0.71).

CONCLUSIONS: GPs and patients found nurse substitution relevant in more than one in ten consultations, although they rarely agreed on which consultations. Follow-up consultations and consultations with older patients were associated with GPs considering nurse substitution appropriate more often. For patients, male and younger patients most often found substitution relevant. High importance of seeing the personal GP may contribute to patient reluctance to nurse substitution, especially for follow-up consultations. The results indicate a need for involving patients' perspective when altering the future roles of primary health care professionals.

BMC Fam Pract 2013 Nov 14;14(1):171

Diabetisk perifer neuropati - hvad bør en praktiserende læge vide?

Charles M

De fleste mennesker med diabetes lider af nerveskader som følge af højt blodsukker. Perifer diabetisk neuropati påvirker de nerver, der fører til fødderne, og det medfører en række symptomer og mulige komplikationer. Enkle og lavpraktiske tests, som udføres i almen praksis, kan hjælpe med til at finde de patienter, der er i risiko for at udvikle fodsår. Metoden betyder, at komplikationer – og i værste fald – amputationer kan undgås. Artiklen skitserer også fremtidige muligheder for at identificere risikopatienterne endnu bedre.

Månedsskrift for Almen Praksis, nr. 11, november 2013, årgang 91, side 920

Psykisk sygdom – en risikofaktor for fysisk sygdom og død

Larsen KK, Ribe AR, Christensen KS, Vestergaard M

Psykisk syge har tit fysiske sygdomme, og lever i gennemsnit kortere end andre dele af befolkningen. En forskergruppe fra Aarhus Universitet ser i denne oversigtsartikel nærmere på det komplekse samspil mellem psykisk og fysisk sygdom, hvor den praktiserende læge spiller en helt særlig rolle. I det moderne sundhedsvæsen, som er præget af stærke monofaglige miljøer, er den praktiserende nemlig læge den eneste, der behandler patienter med både fysiske og psykiske sygdomme. Forskningsprogrammet Mental Health in Primary Care (MEPRICA) ved Aarhus Universitet fokuserer på psykiske lidelser og multisygdom i almen praksis. Artiklen her præsenterer nogle af de temaer, som forskningsprojekterne kredser om. Formålet er at identificere årsager til overdødelighed og underbehandling af psykisk syge, som samtidig lider af fysisk sygdom, så denne gruppe af patienter fremover kan tilbydes en bedre behandling.  

Månedsskrift for Almen Praksis nr. 11, november 2013, årgang 91, side 927

Skal overvægtige voksne tabe sig?

Overvad K, Sandbæk A, Pedersen KB, Sørensen TIA

I Danmark er udviklingen af overvægtige steget markant. Omkring hver anden voksne dansker er over­vægtig og har dermed en højere risiko for at udvikle en lang række sygdomme, herunder sygdomme med mulig dødelig udgang. De fleste overvægtige vil gerne tabe sig, men en stor gruppe overvægtige er faktisk ikke syge af at veje for meget, og slankekure kan for dem betyde kortere liv, viser denne nye rapport fra Videns­råd for Forebyggelse. Rapportens hovedkonklusioner er, at et vægttab blandt raske overvægtige formentlig følges af en lavere sygelighed, men en højere dødelighed. Derfor bør alle, der rådgiver raske over­­vægtige, flytte fokus fra badevægten som eneste facitliste til rådgivning og vejledning om fysisk aktivitet og sunde kostvaner. Undersøgelse af overvægtiges risiko for hjertekarsygdom og diabetes er vigtig for afklaring af, om der er sygdom til stede. Rapporten beskæftiger sig med overvægtige med et BMI på under 35 og altså ikke med ekstrem fedme. 

Rapport, Vidensråd for Forebyggelse (oktober 2013)

Survival of patients with small cell lung cancer undergoing lung resection in England, 1998-2009

Lüchtenborg M, Riaz SP, Lim E, Page R, Baldwin DR, Jakobsen E, Vedsted P, Lind M, Peake MD, Mellemgaard A, Spicer J, Lang-Lazdunski L, Møller H

Abstract

INTRODUCTION: Chemotherapy or chemoradiotherapy is the recommended treatment for small cell lung cancer (SCLC), except in stage I disease where clinical guidelines state there may be a role for surgery based on favourable outcomes in case series. Evidence supporting adjuvant chemotherapy in resected SCLC is limited but this is widely offered.

METHODS: Data on 359 873 patients who were diagnosed with a first primary lung cancer in England between 1998 and 2009 were grouped according to histology (SCLC or non-SCLC (NSCLC)) and whether they underwent a surgical resection. We explored their survival using Kaplan-Meier analysis and Cox regression, adjusting for age, sex, comorbidity and socioeconomic status.

RESULTS: The survival of 465 patients with resected SCLC was lower than patients with resected NSCLC (5-year survival 31% and 45%, respectively), but much higher than patients of either group who were not resected (3%). The difference between resected SCLC and NSCLC diminished with time after surgery. Survival was superior for the subgroup of 198 'elective' SCLC cases where the diagnosis was most likely known before resection than for the subgroup of 267 'incidental' cases where the SCLC diagnosis was likely to have been made after resection.

CONCLUSIONS: These data serve as a natural experiment testing the survival after surgical management of SCLC according to NSCLC principles. Patients with SCLC treated surgically for early stage disease may have survival outcomes that approach those of NSCLC, supporting the emerging clinical practice of offering surgical resection to selected patients with SCLC.

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Child overweight in general practice – parents’ beliefs and expectations – a questionnaire survey study

Merethe K Andersen, Bo Christensen and Jens Søndergaard

Background: Care for overweight children in general practice involves collaboration with parents. Acknowledging the parents’ frames of references is a prerequisite for successful management. We therefore aimed to analyse parental beliefs about the presumed causes and consequences of overweight in children and expectations towards the GP. Moreover, we aimed at comparing the beliefs and expectations of parents of non-overweight children (NOWC) and parents of overweight children (OWC).

Methods: A cross-sectional survey. Data were obtained from a questionnaire exploring parents’ beliefs and expectations regarding overweight in children. The questionnaires were completed by parents following their child’s participation in the five-year preventive child health examination (PCHE).

Parental agreement upon statements concerning beliefs and expectations regarding overweight in children was measured on a Likert scale. Differences in levels of agreement between parents of non-overweight children and parents of overweight children were analysed using Chi-squared test and Fisher’s exact test.

Results: Parents of 879 children completed and returned questionnaires. Around three fourths of the parents agreed that overweight was a health problem. A majority of parents (93%) agreed that the GP should call attention to overweight in children and offer counselling on diet and exercise. Almost half of the parents expected a follow-up programme. Parents of overweight children seemed to agree less upon some of the proposed causes of overweight, e.g. inappropriate diet and lack of exercise. These parents also had stronger beliefs about overweight disappearing by itself as the child grows up.

Conclusions: According to parental beliefs and expectations, general practice should have an important role to play in the management of child overweight. Moreover, our findings suggest that GPs should be aware of the particular beliefs that parents of overweight children may have regarding causes of overweight in their child.

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