Meeting in the middle: Improving communication in primary health care consultations with people with an intellectual disability

The increased presence and participation in Australian society of people with an intellectual disability provides challenges for the provision of primary health care. General practitioners (GPs) identify themselves as ill equipped to provide for this heterogeneous population. A major obstacle to the provision of appropriate health care is seen as inadequate communication between the GP and the person with an intellectual disability, who may or may not be accompanied by a carer or advocate. This qualitative study in which five GPs, three people with intellectual disability, seven carers and two advocates (parent and friend) were interviewed was conducted in Brisbane, Australia. The aim was to better understand the factors that have an impact upon the success of communication in a medical consultation. Findings suggested that GPs were concerned with the aspects of communication difficulties which influenced their ability to adequately diagnose, manage and inform patients. Implications for practice management were also identified. People with intellectual disability reported frustration when they felt that they could not communicate adequately with the GP and annoyance when they were not included in the communication exchange. Carers were strong advocates for the person with intellectual disability, but indicated insufficient skill and knowledge to provide the level of assistance required in the consultation. The outcome was a model of cooperation that outlined the responsibilities of all players in the medical encounter, prior to, during and after the event.

Diagnosis of autistic spectrum disorders in Queensland: Variations in practice

Objective: For both paediatricians and child psychiatrists, referrals to assess possible autistic spectrum disorders (ASD) are increasing. This study examines current practices of medical specialists in the assessment of these disorders. Methods: An anonymous, self-report questionnaire was sent to all Queensland paediatricians and child psychiatrists. The survey elicited frequencies of consultation for ASD, diagnostic method, advice provided and perceived adequacy of training for this work. Results: Responses were received from 79 (85%) eligible paediatricians and 26 (58%) eligible child psychiatrists. For one-third of all clinicians, new consultations for possible ASD occurred as often as 2-3 times per week. Most specialists approached the clinical diagnosis of ASD by considering history from different sources and professional assessments. Paediatricians (86%) were more likely than child psychiatrists (62%) to request genetic studies for children with severe autism (P = 0.01). Both general paediatricians and developmental paediatricians perceived level of training for possible ASD consultations was significantly worse than child psychiatrists (P < 0.001 and P = 0.02, respectively), but no difference was found between paediatric groups (P = 0.27). Perceived adequacy of specialist training was not associated with length of experience in clinical practice. Conclusion: Medical practice in Queensland around diagnosis of ASD is characterized by considerable variability. There is still a long way to go if we are to achieve consistency around medical issues of organic diagnosis and practices impacting on health as well as consideration of differential developmental diagnoses. The finding that recently trained paediatricians felt just as unprepared for this work as their older colleagues suggests that the graduate training response to this 'new morbidity' has not been adequate.

Pseudopregnancy in the bitch

Pseudopregnancy in the bitch is a normal phenomenon. It refers to the dioestrus phase of the bitch's reproductive cycle. It can range in severity from covert pseudopregnancy, in which the signs are barely noticeable, to severe clinical or overt pseudopregnancy. It occurs six to eight weeks following oestrous. The bitch may present with pregnancy-like behaviour including nesting and aggression, excessive mammary enlargement and contractions. These signs are an exaggerated version of the normal signs shown in a normal entire cycling bitch. The exact aetiology behind pseudopregnancy is not known. It is believed to be associated with a rapid decline in serum progesterone concentrations and the resulting surge in prolactin. Treatment may involve conservative management, medical therapy or ovariectomy/ovariohysterectomy. In the past medical therapy has included sex steroids including oestrogens, androgens and progestins. However, due to the frequent incidence and severity of side effects their use is contraindicated. Recommended forms of management incorporate the use of prolactin inhibitors such as cabergoline, metergoline and bromocriptine. These drugs reduce serum levels of prolactin and therefore reduce the development of mammary glands and decrease the behavioural signs associated with overt pseudopregnancy.

Electronic patient records: Achieving best practice in information transfer between hospital and community providers - an integration success story

Effective healthcare integration is underpinned by clinical information transfer that is timely, legible and relevant. The aim of this study was to describe and evaluate a method for best practice information exchange. This was achieved based on the generic Mater integration methodology. Using this model the Mater Health Services have increased effective community fax discharge from 34% in 1999 to 86% in 2002. These results were predicated on applied information technology excellence involving the development of the Mater Electronic Health Referral Summary and effective change management methodology, which included addressing issues around patient consent, engaging clinicians, provision of timely and appropriate education and training, executive leadership and commitment and adequate resourcing. The challenge in achieving best practice information transfer is not solely in the technology but also in implementing the change process and engaging clinicians. General practitioners valued the intervention highly. Hospital and community providers now have an inexpensive, effective product for critical information exchange in a timely and relevant manner, enhancing the quality and safety of patient care.

Attitudes and management of alcohol problems in general practice: Descriptive analysis based on findings of a world health organization international collaborative survey

Aims: To determine if general practitioners' (GPs) experience of education on alcohol, support in their working environment for intervening with alcohol problems, and their attitudes have an impact on the number of patients they manage with alcohol problems. Methods: 1300 GPs from nine countries were surveyed with a postal questionnaire as part of a World Health Organization (WHO) collaborative study. Results: GPs who received more education on alcohol (OR = 1.5; 95% CI, 1.3-1.7), who perceived that they were working in a supportive environment (OR = 1.6; 95% CI, 1.4-1.9), who expressed higher role security in working with alcohol problems (OR = 2.0; 95% CI, 1.5-2.5) and who reported greater therapeutic commitment to working with alcohol problems (OR = 1.4: 95% CI, 1.1-1.7) were more likely to manage patients with alcohol-related harm. Conclusion: Both education and support in the working environment need to be provided to enhance the involvement of GPs in the management of alcohol problems.

Medical student radiology training: What are the objectives for contemporary medical practice?

Rationale and Objectives. The authors attempt to provide a set of objectives for medical student training in radiology for contemporary medical practice. Materials and Methods. A questionnaire containing a list of educational objectives was sent to 32 radiologists in charge of medical student training in radiology at accredited residency programs in Australia and New Zealand. The importance of including each preselected objective in the curriculum was measured by respondents' agreement or disagreement on a scale of 1-6. Opportunity also was given to respondents to suggest objectives other than those presented on the questionnaire. Results. Twenty of the 32 questionnaires were returned, and a set of educational objectives was established based on the responses. The objectives were ranked in importance according to the mean score assigned to each objective by the respondents. Conclusion. This new set of educational objectives for medical student radiology training reflects recent changes in radiologic and medical practice and points to potential future developments.

Experimental analysis of the influence of pest management practice on the efficacy of an endemic arthropod natural enemy complex of the diamondback moth.

Maximizing the contribution of endemic natural enemies to integrated pest management (IPM) programs requires a detailed knowledge of their interactions with the target pest. This experimental field study evaluated the impact of the endemic natural enemy complex of Plutella xylostella (L.) (Lepidoptera: Yponomeutidae) on pest populations in commercial cabbage crops in southeastern Queensland, Australia. Management data were used to score pest management practices at experimental sites on independent Brassica farms practicing a range of pest management strategies, and mechanical methods of natural enemy exclusion were used to assess the impact of natural enemies on introduced cohorts of P. xylostella at each site. Natural enemy impact was greatest at sites adopting IPM and least at sites practicing conventional pest management strategies. At IPM sites, the contribution of natural enemies to P. xylostella mortality permitted the cultivation of marketable crops with no yield loss but with a substantial reduction in insecticide inputs. Three species of larval parasitoids (Diadegma semiclausum Hellen [Hymenoptera: Ichneumonidae], Apanteles ippeus Nixon [Hymenoptera: Braconidae], and Oomyzus sokolowskii Kurdjumov [Hymenoptera: Eulophidae]) and one species of pupal parasitoid Diadromus collaris Gravenhorst (Hymenoptera: Ichneumonidae) attacked immature P. xylostella. The most abundant groups of predatory arthropods caught in pitfall traps were Araneae (Lycosidae) > Coleoptera (Carabidae, Coccinelidae, Staphylinidae) > Neuroptera (Chrysopidae) > Formicidae, whereas on crop foliage Araneae (Clubionidae, Oxyopidae) > Coleoptera (Coccinelidae) > Neuroptera (Chrysopidae) were most common. The abundance and diversity of natural enemies was greatest at sites that adopted IPM, correlating greater P. xylostella mortality at these sites. The efficacy of the natural enemy complex to pest mortality under different pest management regimes and appropriate strategies to optimize this important natural resource are discussed.

Influence of socioeconomic deprivation on the primary care burden and treatment of patients with a diagnosis of heart failure in general practice in Scotland: population based study

Objectives To examine whether there are socioeconomic gradients in die incidence, prevalence, treatment, and follow up of patients with heart failure in primary care. Design Population based study. Setting 53 general practices (307741 patients) participating in the Scottish continuous morbidity recording project between 1 April 1999 and 31 March 2000. Participants 2186 adults with heart failure. Main outcome measures Comorbid diagnoses, frequency of visits to general practitioner, and prescribed drugs. Results 2186 patients with heart failure were seen (prevalence 7.1 per 1000 population, incidence 2.0 per 1000 population). The age and sex standardised incidence of heart failure increased with greater socioeconomic deprivation, from 1.8 per 1000 population in the most affluent stratum to 2.6 per 1000 population in the most deprived stratum (odds ratio 1.44, P=0.0003). On average, patients were seen 2.4 times yearly, but follow up rates were less frequent with increasing socioeconomic deprivation (from 2.6 yearly in the most affluent subgroup to 2.0 yearly in the most deprived subgroup, P=0.00009). Overall, 812 (80.6%) patients were prescribed diuretics, 396 (39.3%) angiotensin converting enzyme inhibitors, 216 (21.4%) beta blockers, 208 (20.7%) digoxin, and 86 (8.5%) spironolactone. The wide discrepancies in prescribing between different general practices disappeared after adjustment for patient age and sex. Prescribing patterns did not vary by deprivation categories on univariate or multivariate analyses. Conclusions Compared with affluent patients, socioeconomically deprived patients were 44% more likely to develop heart failure but 23% less likely to see their general practitioner on an ongoing basis. Prescribed treatment did not differ across socioeconomic gradients.

Encouraging practitioners to use resources: evaluation of the national implementation of a resource to improve the clinical management of alcohol-related problems in Indigenous primary care settings

This paper reports on the evaluation of the implementation of the National Recommendations for the Clinical Management of Alcohol-Related Problems in Indigenous Primary Care Settings undertaken in 2001 through 74 standardized workshops, which sought to determine: ( 1) whether this approach to implementation influenced the likelihood that the National Recommendations would be used; ( 2) whether it influenced participants' willingness to engage with Indigenous patients regarding alcohol-related issues; and ( 3) whether the implementation as a whole influenced both practice and clinicians' willingness to engage. Evaluation included pre-/post-workshop and follow-up questionnaires and a focus group. The findings presented indicate that distribution of clinical resources alone is not sufficient to ensure use and that, particularly for medical practitioners, appropriate introduction not only increases use but also positively influences willingness to engage with alcohol-related problems as part of primary clinical care. Further, the enthusiasm for guideline production should be tempered by the need to develop effective implementation strategies.

Australian and New Zealand practice in intensive care (ANZPIC II: The spectrum of practice in the diagnosis and management of pneumonia in patients requiring mechanical ventilation

This study of ventilated patients investigated current clinical practice in 476 episodes of pneumonia (48% community-acquired pneumonia, 24% hospital-acquired pneumonia, 28% ventilator-associated pneumonia) using a prospective survey in 14 intensive care units (ICUs) within Australia and New Zealand. Diagnostic methods and confidence, disease severity, microbiology and antibiotic use were assessed. All pneumonia types had similar mortality (community-acquired pneumonia 33%, hospital-acquired pneumonia 37% and ventilator-associated pneumonia 24%, P = 0.15) with no inter-hospital differences (P = 0.08-0.91). Bronchoscopy was performed in 26%, its use predicted by admission hospital (one tertiary: OR 9.98, CI 95% 5.11-19.49, P < 0.001; one regional: OR 629, CI 95% 3.24-12.20, P < 0.001), clinical signs of consolidation (OR 3.72, CI 95% 2.09-662, P < 0.001) and diagnostic confidence (OR 2.19, CI 95% 1.29-3.72, P = 0.004). Bronchoscopy did not predict outcome (P = 0.11) or appropriate antibiotic selection (P = 0.69). Inappropriate antibiotic prescription was similar for all pneumonia types (11-13%, P = 0.12) and hospitals (0-16%, P = 0.25). Blood cultures were taken in 51% of cases. For community-acquired pneumonia, 70% received a third generation cephalosporin and 65% a macrolide. Third generation cephalosporins were less frequently used for mild infections (OR 0.38, CI 95% 0.16-0.90, P = 0.03), hospital-acquired pneumonia (OR 0.40, CI 95% 0.23-0.72, P < 0.01), ventilator-associated pneumonia (OR 0.04, CI 95% 0.02-0.13, P < 0.001), suspected aspiration (OR 0.20, CI 95% 0.04-0.92, P = 0.04), in one regional (OR 0.26, CI 95% 0.07-0.97, P = 0.05) and one tertiary hospital (OR 0.14, CI 95% 0.03-0.73, P = 0.02) but were more commonly used in older patients (OR 1.02, CI 95% 1.01-1.03, P = 0.01). There is practice variability in bronchoscopy and antibiotic use for pneumonia in Australian and New Zealand ICUs without significant impact on patient outcome, as the prevalence of inappropriate antibiotic prescription is low. There are opportunities for improving microbiological diagnostic work-up for isolation of aetiological pathogens.

A medical management of interstitial ectopic pregnancy: A 5-year clinical study

Background: Medical treatment of the rare interstitial ectopic pregnancy with methotrexate has been considered an alternative to surgical resection. Aim: To determine the treatment success rate with a single-dose intravenous methotrexate/folinic acid regimen and to identify predictors of treatment outcome. Methods: A 5-year audit (April 2000-August 2005) was carried out, collecting clinical imaging data and serum beta-human chorionic gonadotrophin (beta-hCG). Time taken for complete beta-hCG resolution was recorded, and a negative beta-hCG result was used as an endpoint of successful outcome. Results: Of the 13 cases, two required urgent surgery for rupture on presentation. In the remaining 11 cases, intravenous methotrexate (300 mg) was used, with oral folinic acid rescue (15 mg x 4 doses). There were no side-effects. Complete beta-hCG resolution was achieved in 10 of the 11 medically treated cases (91% success rate), requiring 21-129 days. Successful outcome was seen with initial beta-hCG level as high as 106 634 IU/L and gestation sac as large as 6 cm and a live fetus. Conclusion: The methotrexate/folinic acid regimen used as a one-dose treatment is safe and effective for unruptured interstitial pregnancy, with no side-effects and the advantage of avoiding invasive surgery. Subsequent tubal patency and reproductive function are yet to be ascertained.