Acupuncture for chronic headache in primary care: large,pragmatic, randomised trial

Objective To determine the effects of a policy of “use acupuncture” on headache, health status, days off sick, and use of resources in patients with chronic headache compared with a policy of “avoid acupuncture.”Design Randomised, controlled trial.Setting General practices in England and Wales.Participants 401 patients with chronic headache, predominantly migraine.Interventions Patients were randomly allocated to receive up to 12 acupuncture treatments over three months or to a control intervention offering usual care.Main outcome measures Headache score, SF-36 health status, and use of medication were assessed at baseline, three, and 12 months. Use of resources was assessed every three months.Results Headache score at 12 months, the primary end point, was lower in the acupuncture group (16.2, SD 13.7, n = 161, 34% reduction from baseline) than in controls (22.3, SD 17.0, n = 140, 16% reduction from baseline). The adjusted difference between means is 4.6 (95% confidence interval 2.2 to 7.0; P = 0.0002). This result is robust to sensitivity analysis incorporating imputation for missing data. Patients in the acupuncture group experienced the equivalent of 22 fewer days of headache per year (8 to 38). SF-36 data favoured acupuncture, although differences reached significance only for physical role functioning, energy, and change in health. Compared with controls, patients randomised to acupuncture used 15% less medication (P = 0.02), made 25% fewer visits to general practitioners (P = 0.10), and took 15% fewer days off sick (P = 0.2).Conclusions Acupuncture leads to persisting, clinically relevant benefits for primary care patients with chronic headache, particularly migraine. Expansion of NHS acupuncture services should be considered.     

Managing depression in a changing primary mental healthcare system: comparison of two snapshots of Australian GPs' treatment and referral patterns

Background Significant government spending has resulted in substantial changes to the Australian primary mental healthcare system. Initially producing the Better Outcomes in Mental Health Care (BOiMHC) initiative, this has been replaced by the Better Access to Mental Health Care programme, which allows all general practitioners (GPs) to refer patients for allied psychological health care under Medicare. Aim To examine changes in patient management and referral for care following the BOiMHC initiative.Method Comparison of results of a 2006 postal survey of Australian GPs examining self-reported management of patients with depression with a similar survey conducted in 2001-2002, prior to the BOiMHC initiative.Results One hundred and thirty-three (33%) GPs responded. The main self-reported strategies for managing patients with depression were similar to the previous study: supportive counselling and medication. No significant difference was found in rates of self-reported formal training in psychological treatments. Significantly higher rates of referral for psychological treatments were reported in 2006 than in 2002. Small trends towards higher reported referral for and reported use of psychological treatments by GPs registered for the BOiMHC initiative were noted when compared with those who were not registered.Conclusion While GPs' main reported strategies for managing patients with depression were unchanged, reported referral for psychological therapies was significantly higher in 2006, possibly reflecting the impact of changes to the primary mental healthcare system. Ongoing rigorous evaluation of further changes to the primary mental healthcare system are needed to determine whether they deliver effective, evidence-based care, and thus to inform future programmes.     

Factors influencing recovery from headache after common whiplash.

OBJECTIVE--To assess the relation between pretraumatic and trauma related headache in patients suffering from whiplash. DESIGN--Follow up study of patients examined a mean (SD) of 7.4 (4.2) days after trauma and again at three and six months. SETTING--Patients referred from primary care. SUBJECTS--117 patients (mean age 30.8 (9.5) years. MAIN OUTCOME MEASURES--Prevalence of trauma related headache and the predictive relation by multiple logistic regression between different somatic and psychological variables and trauma related headache at each examination. RESULTS--Prevalence of trauma related headache decreased from 57% to 27%. History of pretraumatic headache proved a significant risk factor for presenting with trauma related headache. A significant relation between trauma related headache and the following variables was found: at seven days the initial wellbeing score, early onset of neck pain, depression scale from the personality inventory, and the initial intensity of neck pain; at three months, intensity of neck pain, and history of pretraumatic headache; and at six months neck pain, pain intensity, and history of pretraumatic headache. CONCLUSIONS--History of pretraumatic headache significantly increases the likelihood of presenting with trauma related headache but only in combination with findings indicative of clinically important injury to the cervical spine.     

Effect of high-quality care on limb function recovery and quality of life after osteoporotic hip fracture surgery in the elderly

Objectives:To evaluate the effect of high-quality care on limb function recovery and quality of life (QOL) after osteoporotic hip fracture (OHF) surgery in the elderly.Methods:116 elderly patients with OHF enrolled in our hospital from January 2017 to December 2019 were assigned into observation group (high-quality care, n=58) and control group (routine care, n=58). After one month of intervention, Harris Hip Score (HHS) and Barthel Index (BI) were used to evaluating limb function and self-care ability, pain intensity numerical rating scale (PINRS) for pain assessment, self-rating anxiety scale (SAS), and self-rating depression scale (SDS) for emotion assessment. Besides, postsurgical complications, QOL and patient satisfaction were examined.Results:HHS and BI were higher in observation group (P<0.05); PINRS, SAS and SDS were lower in observation group (P<0.05); incidence of postsurgical complications in the observation group was significantly lower than that in the control group (P<0.05); QOL and patient satisfaction in the observation group were higher than those in the control group (P<0.05).Conclusion:High-quality care promotes the recovery of limb function, the QOL and the satisfaction of elderly patients.     

What is important, what needs treating? How GPs perceive older patients' multiple health problems: a mixed method research study

ABSTRACT: BACKGROUND: GPs increasingly deal with multiple health problems of their older patients. They have to apply a hierarchical management approach that considers priorities to balance competing needs for treatment. Yet, the practice of setting individual priorities in older patients is largely unexplored. This paper analyses the GPs' perceptions on important and unimportant health problems and how these affect their treatment. METHODS: GPs appraised the importance of health problems for a purposive sample of their older patients in semi-structured interviews. Prior to the interviews, the GPs had received a list of their patients' health problems resulting from a geriatric assessment and were asked to rate the importance of each identified problem. In the interviews the GPs subsequently explained why they considered certain health problems important or not and how this affected treatment. Data was analysed using qualitative content analysis and quantitative methods. RESULTS: The problems GPs perceive as important are those that are medical and require active treatment or monitoring, or that induce empathy or awareness but cannot be assisted further. Unimportant problems are those that are well managed problems and need no further attention as well as age-related conditions or functional disabilities that provoke fatalism, or those considered outside the GPs' responsibility. Statements of professional actions are closely linked to explanations of important problems and relate to physical problems rather than functional and social patient issues. CONCLUSIONS: GPs tend to prioritise treatable clinical conditions. Treatment approaches are, however, vague or missing for complex chronic illnesses and disabilities. Here, patient empowerment strategies are of value and need to be developed and implemented. The professional concepts of ageing and disability should not impede but rather foster treatment and care. To this end, GPs need to be able to delegate care to a functioning primary care team. Trial Registration German Trial Register (DRKS): 00000792.     

Analysis of Trigger Factors in Episodic Migraineurs Using a Smartphone Headache Diary Applications

Background

Various stimuli can trigger migraines in susceptible individuals. We examined migraine trigger factors by using a smartphone headache diary application.

Method

Episodic migraineurs who agreed to participate in our study downloaded smartphone headache diary application, which was designed to capture the details regarding headache trigger factors and characteristics for 3 months. The participants were asked to access the smartphone headache diary application daily and to confirm the presence of a headache and input the types of trigger factors.

Results

Sixty-two participants kept diary entries until the end of the study. The diary data for 4,579 days were analyzed. In this data set, 1,099 headache days (336 migraines, 763 non-migraine headaches) were recorded; of these, 772 headache events had with trigger factors, and 327 events did not have trigger factors. The common trigger factors that were present on headache days included stress, fatigue, sleep deprivation, hormonal changes, and weather changes. The likelihood of a headache trigger was 57.7% for stress, 55.1% for sleep deprivation, 48.5% for fatigue, and 46.5% for any trigger. The headaches with trigger factors were associated with greater pain intensity (p<0.001), headache-related disability (p<0.001), abortive medication use (p = 0.02), and the proportion of migraine (p < 0.001), relative to those without trigger factors. Traveling (odd ratios [OR]: 6.4), hormonal changes (OR: 3.5), noise (OR: 2.8), alcohol (OR: 2.5), overeating (OR: 2.4), and stress (OR:1.8) were significantly associated with migraines compared to non-migraine headaches. The headaches that were associated with hormonal changes or noise were more often migraines, regardless of the preventive medication. The headaches due to stress, overeating, alcohol, and traveling were more often migraines without preventive medication, but it was not evident with preventive medication.

Conclusion

Smartphone headache diary application is an effective tool to assess migraine trigger factors. The headaches with trigger factors had greater severity or migraine features. The type of triggers and the presence of preventive medication influenced the headache characteristics; hence, an investigation of trigger factors would be helpful in understanding migraine occurrences.     

Is Drug Treatment for Dementia Followed Up in Primary Care? A Swedish Study of Dementia Clinics and Referring Primary Care Centres

Purpose

It is largely unknown how the medical treatment of patients diagnosed with dementia is followed up in primary care. Therefore, we studied patient medical records from two dementia clinics and from the referring primary care centres.

Methods

A retrospective study of 241 patients was conducted from April to October 2011 in north west Stockholm, Sweden. Over half (51.5%) of the patients had Alzheimer’s disease (AD), the remainder had mixed AD/vascular dementia (VaD). Eighty-four medical reports from primary care (35% of the study group) were analysed at follow-up 18 months after diagnosis.

Results

All four dementia drugs available on the Swedish market (three cholinesterase inhibitors [donepezil, rivastigmine and galantamine] and memantine) were prescribed at the two dementia clinics. The most commonly used dementia drug was galantamine. There were differences between the two dementia clinics in preference and combination of drugs and of treatment given to male and female patients. At follow-up, 84% were still on dementia medication. Drug use was followed up by the general practitioners (GPs) in two-thirds of the cases. Eighteen per cent of the GPs’ medical records made no reference to the patient’s dementia or treatment even though dementia drugs were included in the list of medications prescribed.

Conclusions

The results indicate that the Swedish guidelines for treatment of cognitive symptoms in AD are being followed in primary care. However, documentation of follow-up of drug treatment was sometimes insufficient, which calls for development of guidelines for complete medical records and medication lists.     

A cluster randomized controlled trial of the effectiveness and cost-effectiveness of Intermediate Care Clinics for Diabetes (ICCD): study protocol for a randomized controlled trial

ABSTRACT: BACKGROUND: World-wide healthcare systems are faced with an epidemic of type 2 diabetes. In the United Kingdom, clinical care is primarily provided by general practitioners (GPs) rather than hospital specialists. Intermediate care clinics for diabetes (ICCD) potentially provide a model for supporting GPs in their care of people with poorly controlled type 2 diabetes and in their management of cardiovascular risk factors. This study aims to (1) compare patients with type 2 diabetes registered with practices that have access to an ICCD service with those that have access only to usual hospital care; (2) assess the cost-effectiveness of the intervention; and (3) explore the views and experiences of patients, health professionals and other stakeholders. METHODS: This two-arm cluster randomized controlled trial (with integral economic evaluation and qualitative study) is set in general practices in three UK Primary Care Trusts. Practices are randomized to one of two groups with patients referred to either an ICCD (intervention) or to hospital care (control).Intervention group: GP practices in the intervention arm have the opportunity to refer patients to an ICCD - a multidisciplinary team led by a specialist nurse and a diabetologist. Patients are reviewed and managed in the ICCD for a short period with a goal of improving diabetes and cardiovascular risk factor control and are then referred back to practice.orControl group: Standard GP care, with referral to secondary care as required, but no access to ICCD.Participants are adults aged 18 years or older who have type 2 diabetes that is difficult for their GPs to control. The primary outcome is the proportion of participants reaching three risk factor targets: HbA1c (<=7.0%); blood pressure (<140/80); and cholesterol (<4 mmol/l), at the end of the 18-month intervention period. The main secondary outcomes are the proportion of participants reaching individual risk factor targets and the overall 10-year risks for coronary heart disease(CHD) and stroke assessed by the United Kingdom Prospective Diabetes Study (UKPDS) risk engine. Other secondary outcomes include body mass index and waist circumference, use of medication, reported smoking, emotional adjustment, patient satisfaction and views on continuity, costs and health related quality of life. We aimed to randomize 50 practices and recruit 2,555 patients. DISCUSSION: Forty-nine practices have been randomized, 1,997 patients have been recruited to the trial, and 20 patients have been recruited to the qualitative study. Results will be available late 2012.Trial registration[ClinicalTrials.gov: Identifier NCT00945204].     

Application of ICHD-II Criteria in a Headache Clinic of China

Background

China has the huge map and the largest population in the world. Previous studies on the prevalence and classification of headaches were conducted based on the general population, however, similar studies among the Chinese outpatient population are scarce. This study aimed to analyze the characteristics of 1843 headache patients enrolled in a North China headache clinic of the General Hospital for Chinese People''s Liberation Army from October 2011 to May 2012, with the International Classification of Headache Disorders, 2nd Edition (ICHD-II).

Methods and Results

Personal interviews were carried out and a detailed questionnaire was used to collect medical records including age, sex and headache characteristics. Patients came from 28 regions of China with the median age of 40.9 (9–80) years and the female/male ratio of 1.67/1. The primary headaches (78.4%) were classified as the following: migraine (39.1%), tension-type headache (32.5%), trigeminal autonomic cephalalgias (5.3%) and other primary headache (1.5%). Among the rest patients, 12.9% were secondary headaches, 5.9% were cranial neuralgias and 2.5% were unspecified or not elsewhere classified. Fourteen point nine percent (275/1843) were given an additional diagnosis of chronic daily headache, including medication-overuse headache (MOH, 49.5%), chronic tension-type headache (CTTH, 32.7%) and chronic migraine (CM, 13.5%). The visual analogue scale (VAS) score of TTH with MOH was significantly higher than that of CTTH (6.8±2.0 vs 5.6±2.0, P<0.001). The similar result was also observed in VAS score between migraine with MOH and CM (8.0±1.5 vs 7.0±1.5, P = 0.004). The peak age at onset of TTH for male and female were both in the 3^rd decade of life. However, the age distribution at onset of migraine shows an obvious sex difference, i.e. the 2^nd decade for females and the 1^st decade for males.

Conclusions/Significance

This study revealed the characteristics of the headache clinic outpatients in a tertiary hospital of North China that migraine is the most common diagnosis. Furthermore, most headaches in this patient population can be classified using ICHD-II criteria.     

Collaboration between general practitioners (GPs) and mental healthcare professionals within the context of reforms in Quebec

Background In the context of the high prevalence and impact of mental disorders worldwide, and less than optimal utilisation of services and adequacy of care, strengthening primary mental healthcare should be a leading priority. This article assesses the state of collaboration among general practitioners (GPs), psychiatrists and psychosocial mental healthcare professionals, factors that enable and hinder shared care, and GPs’ perceptions of best practices in the management of mental disorders. A collaboration model is also developed.Methods The study employs a mixed-method approach, with emphasis on qualitative investigation. Drawing from a previous survey representative of the Quebec GP population, 60 GPs were selected for further investigation.Results Globally, GPs managed mental healthcare patients in solo practice in parallel or sequential follow-up with mental healthcare professionals. GPs cited psychologists and psychiatrists as their main partners. Numerous hindering factors associated with shared care were found: lack of resources (either professionals or services); long waiting times; lack of training, time and incentives for collaboration; and inappropriate GP payment modes. The ideal practice model includes GPs working in multidisciplinary group practice in their own settings. GPs recommended expanding psychosocial services and shared care to increase overall access and quality of care for these patients.Conclusion As increasing attention is devoted worldwide to the development of optimal integrated primary care, this article contributes to the discussion on mental healthcare service planning. A culture of collaboration has to be encouraged as comprehensive services and continuity of care are key recovery factors of patients with mental disorders.     

Behavioural and psychological symptoms of dementia in primary care: a survey of general practitioners in Ireland

Background Management of neuropsychiatric symptoms is a challenging task in primary care. Aims To assess self-reported confidence and knowledge of general practitioners (GPs) regarding the identification and management of behavioural and psychological symptoms of dementia (BPSD).Methods A self-designed two-page paper questionnaire was sent to a random sample of 160 GPs practising in north Dublin. They were asked to evaluate their confidence and knowledge on several aspects of diagnosis and management of BPSD.Results Completed questionnaires were returned from 109 GPs (response rate = 68%), of which 106 were usable. In general, GPs were somewhat critical of their self-reported skills in diagnosing (76.4%) and managing (77.4%) BPSD, as well as in discriminating BPSD from other behavioural disturbances (71.7%). Many of them (67.9%) also encountered difficulty accessing specialist services. There was no correlation between demographic characteristics of GPs or patient caseload with respect to their responses to questionnaire items. Although many GPs (92.5%) highly valued the important role of non-pharmacological interventions in BPSD, none of them reported recommending these in their daily practice.Conclusions Despite the fact that GPs have a wealth of knowledge about BPSD, they are largely critical of their knowledge and management skills of these symptoms. Efforts should be focused on supporting GPs by means of educational interventions that consider all aspects of dementia, but additionally highlight the more challenging neuropsychiatric components of the illness. Health services need to be structured in a way that promotes collaboration between GPs and mental health professionals for a seamless delivery of care.     

General Practitioners Can Evaluate the Material,Social and Health Dimensions of Patient Social Status

Objective

To identify which physician and patient characteristics are associated with physicians'' estimation of their patient social status.

Design

Cross-sectional multicentric survey.

Setting

Fourty-seven primary care private offices in Western Switzerland.

Participants

Random sample of 2030 patients ≥16, who encountered a general practitioner (GP) between September 2010 and February 2011.

Main measures

Primary outcome: patient social status perceived by GPs, using the MacArthur Scale of Subjective Social Status, ranging from the bottom (0) to the top (10) of the social scale.Secondary outcome: Difference between GP''s evaluation and patient''s own evaluation of their social status. Potential patient correlates: material and social deprivation using the DiPCare-Q, health status using the EQ-5D, sources of income, and level of education. GP characteristics: opinion regarding patients'' deprivation and its influence on health and care.

Results

To evaluate patient social status, GPs considered the material, social, and health aspects of deprivation, along with education level, and amount and type of income. GPs declaring a frequent reflexive consideration of their own prejudice towards deprived patients, gave a higher estimation of patients'' social status (+1.0, p = 0.002). Choosing a less costly treatment for deprived patients was associated with a lower estimation (−0.7, p = 0.002). GP''s evaluation of patient social status was 0.5 point higher than the patient''s own estimate (p<0.0001).

Conclusions

GPs can perceive the various dimensions of patient social status, although heterogeneously, according partly to their own characteristics. Compared to patients'' own evaluation, GPs overestimate patient social status.     

'It's really a myriad of different signals, not just the textbook': the complexities of diagnosing depression in gay men in general practice

This paper reports on in-depth interviews with general practitioners (GPs) about their views and experiences of diagnosing depression in gay men - some of whom are living with HIV - and the broader social contexts in which such a diagnosis is located. This analysis is a key outcome of a collaboration between social researchers, primary healthcare researchers, GPs and community partners, to investigate the management of depression in gay men in primary care settings. As the qualitative component of this project, semi-structured in-depth interviews were conducted with 16 GPs with high caseloads of gay men, in three geographical settings in Australia: Sydney, Adelaide and a rural-coastal town. GPs considered the diagnosis and management of depression to be an integral part of primary care, especially in gay male patients. They had a heightened sense of awareness that depression was common in the group of patients they were seeing. Central to diagnosing depression was the ongoing, long-term relationship GPs had with their gay male patients. GPs were vigilant and proactively inquired about depression, taking into account somatic, social and psychological indicators. In their approach to diagnosing depression, GPs considered not only the life circumstances of individual patients but also the broader social context of stigma related to homosexuality, and the effects that the HIV epidemic has had on individuals, especially on gay men who have been living with HIV for a long time.     

Psychological rehabilitation after myocardial infarction: multicentre randomised controlled trial.

OBJECTIVE: To evaluate rehabilitation after myocardial infarction. DESIGN: Randomised controlled trial of rehabilitation in unselected myocardial infarction patients in six centres, baseline data being collected on admission and by structured interview (of patients and spouses) shortly after discharge and outcome being assessed by structured interview at six months and clinical examination at 12 months. SETTING: Six district general hospitals. SUBJECTS: All 2328 eligible patients admitted over two years with confirmed myocardial infarction and discharged home within 28 days. INTERVENTIONS: Rehabilitation programmes comprising psychological therapy, counselling, relaxation training, and stress management training over seven weekly group outpatient sessions for patients and spouses. MAIN OUTCOME MEASURES: Anxiety, depression, quality of life, morbidity, use of medication, and mortality. RESULTS: At six months there were no significant differences between rehabilitation patients and controls in reported anxiety (prevalence 33%) or depression (19%). Rehabilitation patients reported a lower frequency of angina (median three versus four episodes a week), medication, and physical activity. At 12 months there were no differences in clinical complications, clinical sequelae, or mortality. CONCLUSIONS: Rehabilitation programmes based on psychological therapy, counselling, relaxation training, and stress management seem to offer little objective benefit to patients who have experienced myocardial infarction compared with previous reports of smaller trials.     

Physicians report barriers to deliver best practice care for asplenic patients: a cross-sectional survey

Background

Current management of asplenic patients is not in compliance with best practice standards, such as defined by the British Committee for Standards in Haematology. To improve quality of care, factors inhibiting best practice care delivery need to be identified first. With this study, we aimed to identify and quantify physicians'' barriers to adhere to best practice management of asplenic patients in the Netherlands.

Methods and Principal Findings

A cross-sectional survey, preceded by multiple focus group discussions, was performed among Dutch physicians responsible for prevention of infections in asplenic patients, including specialists (of Internal medicine and Surgery) and general practitioners (GPs). Forty seven GPs and seventy three hospital specialists returned the questionnaire, yielding response rates of 47% and 36,5% respectively. Physicians reported several barriers to deliver best practice. For both GPs and specialists, the most frequently listed barriers were: poor patient knowledge (>80% of hospital specialists and GPs) and lack of clarity about which physician is responsible for the management of asplenic patients (50% of Internists, 46% of Surgeons, 55% of GPs). Both GPs and hospital specialists expressed to experience a lack of mutual trust: specialists were uncertain whether the GP would follow their advice given on patient discharge (33–59%), whereas half of GPs was not convinced that specialists'' discharge letters contained the correct recommendations. Almost all physicians (>90%) indicated that availability of a national guideline would improve adherence to best practice, especially if accessible online.

Conclusion

This study showed that, in accordance with reports on international performance, care delivery for asplenic patients in the Netherlands is suboptimal. We identified and quantified perceived barriers by physicians that prevent adherence to post-splenectomy guidelines for the first time. Better transmural collaboration and better informed patients are likely to improve the quality of care of the asplenic patient population. A national, online-available guideline is urgently required.     

Detection of dementia in primary care: comparison of the original and a modified Mini-Cog Assessment with the Mini-Mental State Examination

Background Dementia is considered widely under-detected in primary care, and general practitioners (GPs) frequently ask for easy to use tools to assist in its early detection.Aim To determine the degree of correlation between the Mini-Cog Assessment (Mini-Cog) as performed by GPs and the Mini-Mental State Examination (MMSE).Design of study This was a prospective study (2005, 2006) comparing two cognitive screening instruments.Setting Ten general practices in Austria, with patients with a hitherto undiagnosed suspicion of dementia seen consecutively.Method Sensitivity, specificity and positive and negative predictive values (PPVs and NPVs) of the Mini-Cog (applying both a colour-coded and the original rating method) were assessed for degree of correlation with the MMSE. In phase one GPs examined patients suspected of having dementia using the Mini-Cog; in phase two a neurologist retested them applying the MMSE, a clock-drawing test (CDT) and a routine clinical examination. A questionnaire on the practicability of the Mini-Cog was answered by GPs.Results Of the 107 patients who participated 86 completed the whole study protocol. The Mini-Cog, as performed by the ten GPs, displayed a sensitivity of 0.85 (95% CI: 0.71, 0.98), a specificity of 0.58 (95% CI: 0.46, 0.71), a PPV of 0.47 (95% CI: 0.33, 0.61) and an NPV of 0.90 (95% CI: 0.80, 0.99) as against the MMSE carried out by neurologists. The GPs judged the Mini-Cog useful and time saving.Conclusion The Mini-Cog has a high sensitivity and acceptable specificity in the general practice setting and has proved to be a practicable tool for the diagnosis of dementia in primary care.