Chest pain in daily practice: occurrence, causes and management

QUESTIONS UNDER STUDY: We assessed the occurrence and aetiology of chest pain in primary care practice. These features differ between primary and emergency care settings, where most previous studies have been performed. METHODS: 59 GPs in western Switzerland recorded all consecutive cases presenting with chest pain. Clinical characteristics, laboratory tests and other investigations as well as the diagnoses remaining after 12 months of follow-up were systematically registered. RESULTS: Among 24,620 patients examined during a total duration of 300 weeks of observation, 672 (2.7%) presented with chest pain (52% female, mean age 55 +/- 19(SD)). Most cases, 442 (1.8%), presented new symptoms and in 356 (1.4%) it was the reason for consulting. Over 40 ailments were diagnosed: musculoskeletal chest pain (including chest wall syndrome) (49%), cardiovascular (16%), psychogenic (11%), respiratory (10%), digestive (8%), miscellaneous (2%) and without diagnosis (3%). The three most prevalent diseases were: chest wall syndrome (43%), coronary artery disease (12%) and anxiety (7%). Unstable angina (6), myocardial infarction (4) and pulmonary embolism (2) were uncommon (1.8%). Potentially serious conditions including cardiac, respiratory and neoplasic diseases accounted for 20% of cases. A large number of laboratory tests (42%), referral to a specialist (16%) or hospitalisation (5%) were performed. Twentyfive patients died during follow-up, of which twelve were for a reason directly associated with thoracic pain [cancer (7) and cardiac causes (5)]. CONCLUSIONS: Thoracic pain was present in 2.7% of primary care consultations. Chest wall syndrome pain was the main aetiology. Cardio - vascular emergencies were uncommon. However chest pain deserves full consideration because of the occurrence of potentially serious conditions.

Supervised injection services : what has been demonstrated? A systematic literature review

BACKGROUND: Supervised injection services (SISs) have been developed to promote safer drug injection practices, enhance health-related behaviors among people who inject drugs (PWID), and connect PWID with external health and social services. Nevertheless, SISs have also been accused of fostering drug use and drug trafficking. AIMS: To systematically collect and synthesize the currently available evidence regarding SIS-induced benefits and harm. METHODS: A systematic review was performed via the PubMed, Web of Science, and ScienceDirect databases using the keyword algorithm [("supervised" or "safer") and ("injection" or "injecting" or "shooting" or "consumption") and ("facility" or "facilities" or "room" or "gallery" or "centre" or "site")]. RESULTS: Seventy-five relevant articles were found. All studies converged to find that SISs were efficacious in attracting the most marginalized PWID, promoting safer injection conditions, enhancing access to primary health care, and reducing the overdose frequency. SISs were not found to increase drug injecting, drug trafficking or crime in the surrounding environments. SISs were found to be associated with reduced levels of public drug injections and dropped syringes. Of the articles, 85% originated from Vancouver or Sydney. CONCLUSION: SISs have largely fulfilled their initial objectives without enhancing drug use or drug trafficking. Almost all of the studies found in this review were performed in Canada or Australia, whereas the majority of SISs are located in Europe. The implementation of new SISs in places with high rates of injection drug use and associated harms appears to be supported by evidence.

Gènere i sexoafectivitat segons els adolescents dels usuaris dels centres oberts de la ciutat de Girona

L’objectiu d’aquest treball és conèixer la percepció que tenen els adolescents usuaris dels centres oberts de la ciutat de Girona sobre la sexualitat, l’afectivitat, quins rols de gènere se’n deriven i quines creences els sustenten. El disseny del treball ha estat qualitatiu, observacional, grups de discussió. Pel que fa als subjectes i al mètode, la població seleccionada ha estat de 33 adolescents i joves d’edats compreses entre els 12 i els 22 anys, usuaris de quatre centres oberts de Girona: el centre obert de Taialà, el Centre Obert de Font de la Pólvora (Onyar), el Centre Obert de Santa Eugènia i el Centre Obert del Barri Vell. Es van dur a terme grups de discussió d’una hora de duració sense descans amb d’entre 6 i 8 persones a partir d’un guió format per diversos mites i frases en relació a diversos temes (El festeig, la virginitat, la curiositat pel cos i per la sexualitat, els anticonceptius i les principals fonts d’informació) sobre les que havien de dir si estaven d’acord o no i qui creien que les deia (si un noi o una noia). Sobre els resultats del treball cal dir que s’ha observat la persistència d’algunes creences del model del amor romàntic en relació al rols de gènere com la definició de la dona vinculada a papers de cura i prevenció, una dona que té accés a la sexualitat però segueix estan catalogada per la vivència d’aquesta essent una persona “respectable” o una “puta”, que pren un rol més actiu en la iniciativa però no el l’assertivitat en les relacions; i un home, més impulsiu i sexual. En relació als comportaments sexuals destacar l’embaràs no desitjat com la principal preocupació de les relacions i el desconeixement/confusió entre els mètodes anticonceptius i de barrera disponibles a la xarxa de salut. Apareix la pornografia com a model emergent de relacions sexuals i models de relació entre homes i dones, en contraposició a altres fonts de informació i consulta tradicionals com els amics que segueixen essent la més significativa, la família, els serveis socials i educatius, i Internet. Com a conclusió cal dir que queda palesa la necessitat de incorporar una perspectiva de gènere en la formació curricular dels joves i el fet de seguir replantejant les millors estratègies d’intervenció per una concepció integradora de la sexualitat

Système Sentinella: adiposité et troubles du comportement alimentaire chez les 2 à 20 ans

Ce rapport s'inscrit dans le cadre du mandat conjoint "Système Sentinella : adiposité et troubles du comportement alimentaire chez les 2 à 20 ans" du système de surveillance Sentinella et de l'Office fédéral de la santé publique (OFSP). Le mandat a pour but général d'étudier la fréquence et l'aboutissement des consultations avec signalement d'adiposité (A) ou de troubles du comportement alimentaire (TCA) de patients âgés de 2 à 20 ans dans la patientèle des médecins de 1er recours participant en Suisse au système de veille Sentinella, d'identifier les besoins de ces derniers en matière de soutien et de formation, et enfin d'élaborer des recommandations à l'attention de l'OFSP et des médecins de famille, relatives à cette problématique.

Economic grand rounds: financial burden of medical care and risk of forgoing care among Europeans with depressive symptoms

Little is known about the financial burden of individuals with depressive symptoms. This study explored that burden, using data from the Survey of Health, Ageing, and Retirement in Europe. To assess the association between depressive symptoms and the individuals' financial burden for medical care and whether they forwent medical care because of costs, logistic regressions were performed that adjusted for age, gender, marital status, education, and chronic diseases. A total of 16,696 noninstitutionalized individuals aged 50-79 years were included in the study. Individuals with depressive symptoms and those without such symptoms bore a similar financial burden. However, individuals with depressive symptoms were at increased risk of forgoing care because of costs, which may worsen their health and financial situation

Effectiveness of pharmacist care in the improvement of adherence to antidepressants: a systematic review and meta-analysis

BACKGROUND: Pharmacists can play a decisive role in the management of ambulatory patients with depression who have poor adherence to antidepressant drugs. OBJECTIVE: To systematically evaluate the effectiveness of pharmacist care in improving adherence of depressed outpatients to antidepressants. METHODS: A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted. RCTs were identified through electronic databases (MEDLINE, Cochrane Central Register of Controlled Trials, Institute for Scientific Information Web of Knowledge, and Spanish National Research Council) from inception to April 2010, reference lists were checked, and experts were consulted. RCTs that evaluated the impact of pharmacist interventions on improving adherence to antidepressants in depressed patients in an outpatient setting (community pharmacy or pharmacy service) were included. Methodologic quality was assessed and methodologic details and outcomes were extracted in duplicate. RESULTS: Six RCTs were identified. A total of 887 patients with an established diagnosis of depression who were initiating or maintaining pharmacologic treatment with antidepressant drugs and who received pharmacist care (459 patients) or usual care (428 patients) were included in the review. The most commonly reported interventions were patient education and monitoring, monitoring and management of toxicity and adverse effects, adherence promotion, provision of written or visual information, and recommendation or implementation of changes or adjustments in medication. Overall, no statistical heterogeneity or publication bias was detected. The pooled odds ratio, using a random effects model, was 1.64 (95% CI 1.24 to 2.17). Subgroup analysis showed no statistically significant differences in results by type of pharmacist involved, adherence measure, diagnostic tool, or analysis strategy. CONCLUSIONS: These results suggest that pharmacist intervention is effective in the improvement of patient adherence to antidepressants. However, data are still limited and we would recommend more research in this area, specifically outside of the US.

Profile, cost and pattern of prescriptions for polymedicated patients in Catalonia (Spain).

OBJECTIVES: Polypharmacy is one of the main management issues in public health policies because of its financial impact and the increasing number of people involved. The polymedicated population according to their demographic and therapeutic profile and the cost for the public healthcare system were characterised. DESIGN: Cross-sectional study. SETTING: Primary healthcare in Barcelona Health Region, Catalonia, Spain (5 105 551 inhabitants registered). PARTICIPANTS: All insured polymedicated patients. Polymedicated patients were those with a consumption of ≥16 drugs/month. MAIN OUTCOMES MEASURES: The study variables were related to age, gender and medication intake obtained from the 2008 census and records of prescriptions dispensed in pharmacies and charged to the public health system. RESULTS: There were 36 880 polymedicated patients (women: 64.2%; average age: 74.5±10.9 years). The total number of prescriptions billed in 2008 was 2 266 830 (2 272 920 total package units). The most polymedicated group (up to 40% of the total prescriptions) was patients between 75 and 84 years old. The average number of prescriptions billed monthly per patient was 32±2, with an average cost of 452.7±27.5. The total cost of those prescriptions corresponded to 2% of the drug expenditure in Catalonia. The groups N, C, A, R and M represented 71.4% of the total number of drug package units dispensed to polymedicated patients. Great variability was found between the medication profiles of men and women, and between age groups; greater discrepancies were found in paediatric patients (5-14 years) and the elderly (≥65 years). CONCLUSIONS: This study provides essential information to take steps towards rational drug use and a structured approach in the polymedicated population in primary healthcare.

Sähkönjakeluverkon ja sähköasemien kehittämissuunnitelma

Tämän työn tavoitteena on tarkastella keskijänniteverkonja sähköasemien kehittämistarpeita kahdella kohdealueella Kymenlaakson Sähköverkko Oy:n verkossa. Tarkastelun pohjatiedoiksi selvitettiin verkon sähköinen nykytila, luotettavuus, verkon topologia, kuormitusten jakautuminen ja muodostettiintulevaisuuden kuormitusennusteet. Lisäksi tarkasteltiin sähköasemien korvattavuus. Keskeiseksi työn sisällöksi muodostui kevytsähköasemien eri sijoituspaikkojen kannattavuustarkastelut, ottaen huomioon uuden keskijännitesyöttöpisteen vaikutukset keskijänniteverkon vahvistustarpeisiin, häviöihin ja käyttövarmuuteen. Laskelmat suoritettiin elinkaarikustannusperiaatteella huomioiden investointien, keskeytyksestä aiheutuneen haitan, häviöiden, kunnossapidon javiankorjauksen kustannukset. Työn tuloksena saatiin investointistrategiaehdotukset, joiden pohjalta verkkoyhtiö voi tehdä lähitulevaisuuden ratkaisuja sekä valmistautua tuleviin investointeihin.

Hoitoketjun kustannukset perusterveydenhuollosta erikoissairaanhoitoon: Case Lappeenranta ja Imatra

Työn tavoitteena oli selvittää perusterveydenhuollon ja erikoissairaanhoidon välillä kulkevien lappeenrantalaisten (34 potilasta) ja imatralaisten (20 potilasta) hoitoketjun kustannukset ja hoitoajat, sekä analysoida niitä. Kustannusten ja hoitoketjun läpimenoaikojen esittämisessä käytettiin kustannuskertymäajattelua. Tutkimuksessa tutkittiin prosessien ohjauksen ja toiminnanohjauksen teoriaa sekä terveydenhuollossa että teollisuudessa, ja kustannuslaskennan perusteita. Huomattiin, että erityisesti lean -ajattelua voidaan käyttää myös terveydenhuollossa ja hoitoketjuja tarkasteltaessa. Empiirisessä osuudessa tarkasteltiin Lappeenrannan ja Imatran tutkittavien kolmen potilasryhmän kustannuksia ja hoitoaikoja kustannuskertymäkäyrien avulla. Tarkastelussa olivat kaupunkien ja potilasryhmien maksimi-, minimi- ja mediaanikustannuspotilaan hoitoketjun kustannukset ja läpimenoajat. Keskeisenä tuloksena havaittiin, että perusterveydenhuollon osuus kustannuksista oli suuri etenkin potilailla, joilla oli pitkä läpimenoaika hoitoketjussa, sillä hoitoaika painottui tällöin terveyskeskussairaalaan. Hyvin lyhyen läpimenoajan potilailla taas erikoissairaanhoidon osuus kustannuksista oli suurempi, mutta tällaiset potilaat olivat lähinnä minimi-, tai korkeintaan mediaanikustannuspotilaita. Päiväkohtainen kustannus havaittiin erikoissairaanhoidossa korkeammaksi, mutta perusterveydenhuollon terveyskeskussairaalahoito nousi maksimikustannuspotilailla aina selvästi suurimmaksi kustannuksen aiheuttajaksi. Havaittiin myös, että potilaiden lyhyt keskussairaalahoito ei takaa alentuneita hoitoketjun kokonaiskustannuksia. Työssä havaittiin, että perusterveydenhuollon toimivuus on koko terveydenhuollon toimivuuden ja tuottavuuden selkäranka. Erityisesti keskeisiä osia, mihin tulee kiinnittää huomiota hoitoketjussa, ovat potilaan sijoittaminen oikeinkeskussairaalahoitoon tultaessa ja sieltä lähdettäessä. Muun muassa näillä tavoilla voidaan karsia potilaiden ylipitkiä hoitojaksoja perusterveydenhuollossa tai potilaan jäämistä kiertämään hoitoketjuun.

Patients who attend a private practice vs a university outpatient clinic: how do they differ?

Although interpersonal continuity is commonly assumed to be essential for care, some patients prefer to attend a university outpatient clinic where physicians change regularly and interpersonal continuity of care is not ensured. The aim of this exploratory study was to evaluate the differences between patients attending a university outpatient clinic and patients frequenting a private practice, explore their patterns of care-seeking and their understanding of continued care. We conducted a cross-sectional study of patients attending the university medical outpatient clinic (OC) in Lausanne, Switzerland and ten randomly selected private general practices (PP). Eligible patients were >30 years, Swiss nationals or long term residents, with one or more chronic conditions and attending the same practice for >3 years. They were asked to complete a questionnaire on sociodemographic data, use of medical resources and reasons for choosing and remaining at the same practice. Semi-structured interviews were conducted with a randomly selected subset of 26 patients to further explore their preferences. 329 patient questionnaires were completed, 219 by PP and 110 by OC patients. OC patients tended to be of lower socioeconomic status than PP patients. The main reason for choosing a PP were personal recommendation, while a higher percentage of patients chose the OC because they could obtain a first appointment quickly. A higher percentage of PP patients accorded importance to physician communication skills and trust, whereas a higher percentage of OC patients favoured investigation facilities. Qualitative data suggested that although OC and PP patients reported different reasons for consulting, their expectations on the medical and relationship level were similar. Our study suggests that the two groups of patients belong to different social backgrounds, have different patterns of care-seeking and attach importance to different aspects of care continuity. However, patients' expectations and perceptions of the physician-patient relationship are similar.

Inmigración y formación continuada en el colectivo de enfermería de la región sanitaria de Lleida

El aumento significativo de la inmigración en los últimos años supone un nuevo reto para la enfermería. Objetivos: conocer la situación actual de la formación de enfermería respecto a la inmigración, su interés por formarse y las dificultades y necesidades que tienen en materia de inmigración. Metodología: estudio descriptivo y transversal analizando una muestra representativa de todos los profesionales de enfermería colegiados en la provincia de Lleida. Para la recogida de datos se utilizó un cuestionario y el análisis estadístico se realizó con el programa informático SPSS versión 13.0. Resultados: más del 90% de los profesionales de enfermería de la provincia de Lleida son mujeres menores de 50 años y que mayoritariamente trabajan en atención hospitalaria. No obstante el interés expresado por temas relacionados con la inmigración, sólo el 24% ha realizado algún tipo de formación al respecto. La mayoría también reconoce tener problemas de comunicación con los inmigrantes. Las sugerencias recogidas en el cuestionario se categorizaron en modelos de integración y en formación. Conclusión: la formación de enfermería en inmigración es baja y se debe a su elevado coste y a que no se realiza en horario laboral. En términos generales, los profesionales de enfermería que se dedican a la Atención Primaria de salud, muestran mayor interés por formarse y mayor flexibilidad para modificar los protocolos y cuidados que sus homónimos hospitalarios.

Essential surgery: the way forward.

INTRODUCTION: Very little surgical care is performed in low- and middle-income countries (LMICs). An estimated two billion people in the world have no access to essential surgical care, and non-surgeons perform much of the surgery in remote and rural areas. Surgical care is as yet not recognized as an integral aspect of primary health care despite its self-demonstrated cost-effectiveness. We aimed to define the parameters of a public health approach to provide surgical care to areas in most need. METHODS: Consensus meetings were held, field experience was collected via targeted interviews, and a literature review on the current state of essential surgical care provision in Sub-Saharan Africa (SSA) was conducted. Comparisons were made across international recommendations for essential surgical interventions and a consensus-driven list was drawn up according to their relative simplicity, resource requirement, and capacity to provide the highest impact in terms of averted mortality or disability. RESULTS: Essential Surgery consists of basic, low-cost surgical interventions, which save lives and prevent life-long disability or life-threatening complications and may be offered in any district hospital. Fifteen essential surgical interventions were deduced from various recommendations from international surgical bodies. Training in the realm of Essential Surgery is narrow and strict enough to be possible for non-physician clinicians (NPCs). This cadre is already active in many SSA countries in providing the bulk of surgical care. CONCLUSION: A basic package of essential surgical care interventions is imperative to provide structure for scaling up training and building essential health services in remote and rural areas of LMICs. NPCs, a health cadre predominant in SSA, require training, mentoring, and monitoring. The cost of such training is vastly more efficient than the expensive training of a few polyvalent or specialist surgeons, who will not be sufficient in numbers within the next few generations. Moreover, these practitioners are used to working in the districts and are much less prone to gravitate elsewhere. The use of these NPCs performing "Essential Surgery" is a feasible route to deal with the almost total lack of primary surgical care in LMICs.

Mechanisms of action of brief alcohol interventions remain largely unknown - a narrative review.

A growing body of evidence has shown the efficacy of brief intervention (BI) for hazardous and harmful alcohol use in primary health care settings. Evidence for efficacy in other settings and effectiveness when implemented at larger scale are disappointing. Indeed, BI comprises varying content; exploring BI content and mechanisms of action may be a promising way to enhance efficacy and effectiveness. Medline and PsychInfo, as well as references of retrieved publications were searched for original research or review on active ingredients (components or mechanisms) of face-to-face BIs [and its subtypes, including brief advice and brief motivational interviewing (BMI)] for alcohol. Overall, BI active ingredients have been scarcely investigated, almost only within BMI, and mostly among patients in the emergency room, young adults, and US college students. This body of research has shown that personalized feedback may be an effective component; specific MI techniques showed mixed findings; decisional balance findings tended to suggest a potential detrimental effect; while change plan exercises, advice to reduce or stop drinking, presenting alternative change options, and moderation strategies are promising but need further study. Client change talk is a potential mediator of BMI effects; change in norm perceptions and enhanced discrepancy between current behavior and broader life goals and values have received preliminary support; readiness to change was only partially supported as a mediator; while enhanced awareness of drinking, perceived risks/benefits of alcohol use, alcohol treatment seeking, and self-efficacy were seldom studied and have as yet found no significant support as such. Research is obviously limited and has provided no clear and consistent evidence on the mechanisms of alcohol BI. How BI achieves the effects seen in randomized trials remains mostly unknown and should be investigated to inform the development of more effective interventions.