Experiences of appearance-related teasing and bullying in skin diseases and their psychological sequelae: results of a qualitative study

Acne, psoriasis and atopic eczema are common diseases and have been consistently associated with adverse psychological sequelae including stigmatization. Being teased on the basis of appearance has been associated with psychiatric morbidity in children and adolescents. The objective of this qualitative study was to explore the experiences of teasing and bullying in patients with acne, psoriasis and eczema, and the role of appearance-related teasing and bullying as mediators of psychological morbidity in these patients. Data collection consisted of 62 in-depth semi-structured interviews with patients with acne, psoriasis or atopic eczema recruited from both specialist dermatology and general practices. Data analysis was cumulative and concurrent throughout the data collection period reflecting a grounded theory approach. Analysis followed the analytic induction method, allowing themes to emerge from the data. Teasing, taunting or bullying was a considerable problem for a significant minority of acne, psoriasis and atopic eczema participants. Themes that emerged were the universally negative nature of the teasing, the use of teasing as an instrument of social exclusion, and as a means of establishing or enforcing power relationships, teasing related to contagion and fear, the emotional and psychological sequelae of teasing and the theme of 'insensate' teasing. For those who had suffered teasing or bullying, this was causally linked in respondents' accounts with psychological sequelae, especially self-consciousness and effects on self-image and self-esteem. Experiences of teasing and bullying were found to have principally occurred during the adolescence of participants and the perpetrators were other adolescents, but there were findings of respondents with psoriasis also having been subjected to ridicule or derogatory remarks by health professionals. Teasing, taunting and bullying may represent an underappreciated source of psychological morbidity in children and adolescents with these common skin diseases.

Macrocytosis--an Australian general practice perspective

BACKGROUND

Clinicians' approaches to identifying and investigating red blood cell macrocytosis are variable. There is little literature on the Australian primary care approach.

METHODS

Mean corpuscular volume (MCV) in blood counts from an urban Australian general practice were calculated and general practitioners in the surrounding division were surveyed on their experience of and approach to investigating macrocytosis.

RESULTS

Mean corpuscular volume above 100 fL was found in 1.7% of patients, and 7.3% had an MCV above 96 fL. Ninety-four percent of responding GPs replied they would further investigate this clinical finding, particularly at levels above 100 fL. Alcohol excess and vitamin B12 deficiency were the most common single causes of macrocytosis in their experience.

DISCUSSION

Macrocytosis can be a marker for disease and it is important to identify and investigate its presence. Further research is needed to clarify the reference range for healthy adults in general practice and to formulate evidence based clinical guidelines for investigating isolated macrocytosis.

Comparative reactogenicity and immunogenicity of 23 valent pneumococcal vaccine administered by intramuscular or subcutaneous injection in elderly adults

23 Valent pneumococcal vaccine is provided to the elderly through public health programs in many countries. However there is no clear recommendation regarding its route of administration (subcutaneous or intramuscular). In a randomised, observer blind study of 254 elderly subjects, the immunogenicity of a 23 valent pneumococcal vaccine was not influenced by its route of administration. A low rate of systemic adverse reactions was observed with the vaccine (subcutaneous and intramuscular both 6.3%). Local adverse reaction rates were; intramuscular 7.1% and subcutaneous 18.9% and these were predicted by: * Pre-vaccination antibody titres>1 microg/ml, odds ratio 22.4 (8.06-74.84) compared with pre-vaccination antibody titre<1 microg/ml. * Female gender, odds ratio 5.0 (1.85-14.83) compared with male gender. * Subcutaneous injection route, odds ratio 3.20 (1.13-9.13) compared with intramuscular injection route. * Female gender subcutaneous injection route, odds ratio 2.99 (1.10-8.70) compared with female gender intramuscular injection route. These data support the intramuscular injection of 23 valent pneumococcal vaccine, especially in elderly females.

Psychological sequelae of acne vulgaris: results of a qualitative study

OBJECTIVE

To investigate the psychological sequelae of acne vulgaris.

DESIGN

Qualitative study using a grounded-theory approach.

SETTING

General practices and specialty dermatology practices in Newcastle, Australia.

PARTICIPANTS

Patients with current acne recruited from the practices.

METHOD

We used semistructured interviews and recorded participants' comments verbatim. Data analysis was cumulative and concurrent throughout the data-collection period. Coding and analysis was done in the inductive tradition.

MAIN FINDINGS

Interviews were conducted with 26 subjects who represented a range of ages and acne severity. Psychological morbidity was considerable. Though participants had mood and anxiety symptoms, these symptoms tended to be subsyndromal and evanescent. More prominent symptoms were embarrassment, impaired self-image, low self-esteem, self-consciousness, frustration, and anger. Some subjects thought that acne had affected their personalities permanently and adversely. Psychological sequelae were attributed to the effects of facial acne on appearance.

CONCLUSION

The psychological effects of acne can be considerable. The psychological morbidity is complex and often does not conform to standard psychiatric disease criteria. Recognition and management of the psychological sequelae of acne by general practitioners is of considerable importance.

Definition of needle length required for intramuscular deltoid injection in elderly adults: an ultrasonographic study

An ultrasound study in elderly patients (> or =65 years) showed that body mass index (BMI) was strongly correlated with deltoid subcutaneous layer thickness in males (r = 0.69 dominant arm, 0.71 non-dominant arm) and females (r = 0.79 both arms). Females with the same BMI as males had significantly thicker subcutaneous layers (p = 0.0001) and thinner muscle layers (p = 0.0003). Minimal needle length required for deltoid intramuscular injection where the needle was entered at 90 degrees to the long axis of the humerus was defined by BMI group. In all BMI males and females, BMI <35, intramuscular injection could be achieved with a 25 mm long needle, whilst in females BMI >35, a 32 mm long needle is required. These data will be used in studies to resolve the clinical equipoise regarding the optimal route of administration (intramuscular versus subcutaneous) of vaccines (e.g. influenza and pneumococcal vaccines), which are provided through public health programs for the elderly.

Reactogenicity and immunogenicity of an inactivated influenza vaccine administered by intramuscular or subcutaneous injection in elderly adults

In many countries there is no clear recommendation regarding the preferred route of administration of inactivated influenza vaccines. In a randomised, observer blind study of 720 elderly subjects, a split, trivalent influenza vaccine was significantly more immunogenic for both A strains (H3N2 and H1N1, p = 0.0016 and 0.003, respectively) when given intramuscularly compared to subcutaneously. This difference was due entirely to a gender effect, with females in the intramuscular (IM) group having a significantly greater serological response than females in the subcutaneous (SC) group for both of these strains. Similar results were seen with local adverse effects. These data suggest that vaccination practices that ensure intramuscular injection are required for optimal administration of influenza vaccines in the elderly.

The effectiveness of nutrition counselling by Australian General Practitioners

OBJECTIVE

To determine whether General Practitioners (GPs) consider or provide nutrition counselling for hypertension, diabetes, lipid disorders, ischaemic heart disease (IHD), overweight or obesity, and whether GPs include assessment of the patient's usual diet, assessment of the patient's readiness to change their diet, provision and discussion of nutrition leaflets when counselling.

DESIGN

A self-completed questionnaire.

SETTING

New South Wales, Australia.

SUBJECTS

A total of 399 GPs were surveyed using a division mailing list.

METHODS

Questionnaires were distributed in May 2004 with two reminders provided at four-weekly intervals.

RESULTS

Of the 399 GPs, 28 no longer practiced at the address while nine were on extended leave. Of the remaining 362, 50% responded, 5% declining to participate, while 163 (45%) completed the questionnaire. GPs were less likely to strongly agree to consider nutrition for hypertension (37%), IHD (61%) and overweight (68%), than diabetes (86%), lipid disorders (82%) and obesity (83%). They were also less likely to strongly agree to provide nutrition for hypertension (22%), IHD (46%) and overweight (45%), than diabetes (79%), lipid disorders (71%) and obesity (68%). In total, 97% of GPs provided some nutrition counselling, with 66% 'often' assessing the patients diet and 59% 'often' assessing the patient's readiness to change their diet. In total, 45% were unaware of stage of change behaviour theory. A total of 85% used nutrition leaflets and 59% 'often' discussed these with their patients.

CONCLUSIONS

Determining what are the barriers to nutrition counselling for hypertension, IHD and overweight is urgently needed. Educating GPs on stage of change behaviour theory could increase the efficacy of the counselling provided.

Patients' perceptions of isotretinoin, depression and suicide--a qualitative study

BACKGROUND

Isotretinoin is an effective acne medication. The evidence for it causing depression and suicide, although widely publicised, remains uncertain.

METHODS

Twenty-six semi-structured interviews with patients with acne were coded and subjected to thematic analysis.

RESULTS

Isotretinoin was perceived to be effective but dangerous. The most well known adverse effects were depression and suicide.

DISCUSSION

The overemphasis of serious psychological adverse events in patients might discourage the use of isotretinoin by those who might benefit from it.

Isotretinoin, depression and suicide: a review of the evidence

There is currently considerable controversy regarding a proposed causal relationship between the use of isotretinoin and depression and suicide. A search was made of the MEDLINE, EMBASE and PsychINFO databases using the search terms 'isotretinoin', 'depression' and 'suicide'. Despite numerous case reports linking isotretinoin to depression, suicidal ideation and suicide, there is, as yet, no clear proof of an association. While isotretinoin, used to treat acne vulgaris, has not been demonstrated to be associated with depression or suicide, the possibility of a relatively rare idiosyncratic adverse effect remains. GPs have a role in the clinical application of these findings.

A systematic review of the evidence for 'myths and misconceptions' in acne management: diet, face-washing and sunlight

BACKGROUND

Lay perceptions that diet, hygiene and sunlight exposure are strongly associated with acne causation and exacerbation are common but at variance with the consensus of current dermatological opinion.

OBJECTIVES

The objective of this study was to carry out a review of the literature to assess the evidence for diet, face-washing and sunlight exposure in acne management.

METHODS

Original studies were identified by searches of the Medline, EMBASE, AMED (Allied and Complementary Medicine), CINAHL, Cochrane, and DARE databases. Methodological information was extracted from identified articles but, given the paucity of high quality studies found, no studies were excluded from the review on methodological grounds.

RESULTS

Given the prevalence of lay perceptions, and the confidence of dermatological opinion in rebutting these perceptions as myths and misconceptions, surprisingly little evidence exists for the efficacy or lack of efficacy of dietary factors, face-washing and sunlight exposure in the management of acne. Much of the available evidence has methodological limitations.

CONCLUSIONS

Based on the present state of evidence, clinicians cannot be didactic in their recommendations regarding diet, hygiene and face-washing, and sunlight to patients with acne. Advice should be individualized, and both clinician and patient cognizant of its limitations.

Diagnosis and management of dementia in general practice

BACKGROUND

The assessment and management of dementia has changed in the past 5 years with the introduction of new drugs to combat dementia. In addition, services available for patients with dementia and the means of accessing these services is constantly changing.

OBJECTIVE

This article discusses the assessment and management of dementia using two case studies. The case studies raise issues about screening and accessing the new drugs for a patient with early dementia, care planning, and the involvement of the carer for a patient with more advanced disease.

DISCUSSION

As the population ages, dementia is an increasingly important part of general practice. It is important general practitioners are aware of early detection issues, and understand basic screening as well as the possibility of accessing new treatments and community management for patients with dementia.

Coping with redundancy: A mentorship program for men

The idea of a small group mentorship program was developed from the concept that small groups might, in some small degree, replace the companionship that men who had been made redundant had experienced in the workplace and in social activities related to work, and that, as a result, participants? health would improve. It was thought these groups would function better if one or two unemployed peers who could demonstrate some positive approaches to the experience of unemployment were identified. This report documents the use of a small group mentorship intervention among 126 retrenched and unemployed men. The aims of the program were to determine the effectiveness of the mentorship program in improving a range of outcome measures, including improvement in health and wellbeing, increased confidence and skills in job search behaviours, and enhanced social networking/ reduced isolation. The program was evaluated using quantitative and qualitative methodology. The mentorship program was found to be an effective intervention to significantly improve outcome measures for depression and anxiety and social interaction for retrenched men. It is recommended that small group mentoring programs be more generally offered to retrenched men to build skills, to promote social connectivity and to improve men?s health and wellbeing.

The role of the general practitioner and the dietitian in patient nutrition management

There is mounting evidence that nutrition plays an important role in the aetiology and management of many diseases affecting Australians. Nutrition counselling provides a strategy for not only reducing patient suffering, but also for reducing the health care costs associated with these illnesses. At the forefront of providing nutrition counselling to Australians are General Practitioners (GPs) and Dietitians. Australian data shows that GPs encounter many patients with the chronic diseases that have nutrition in their aetiology and management. Although this presents opportunities to provide nutrition counselling, overseas literature suggests that often nutrition counselling opportunities are not taken up. At present, there is little evidence to support whether this problem exists in Australia, or the magnitude of the problem. Whilst evidence suggests there are barriers for GPs in providing nutrition counselling, there is conflicting evidence on how these influence the GP's decision to provide such counselling. Overseas studies have also identified barriers for GPs to refer to dietitians to provide nutrition counselling, however there is no evidence to identify whether these barriers exist in Australia. Whilst various strategies have been implemented to aid in the provision of effective nutrition management to the Australian public, there is little evidence on the efficacy of these. Research is needed in the above areas if effective patient nutrition management is to be implemented in Australia.

The management of dementia in general practice. A field test of guidelines

INTRODUCTION

Guidelines for the management of dementia in non-institutionalized patients living in the community were developed by a broadly representative group. We assessed their usefulness.

METHOD

The draft guidelines included emphasis on psychosocial issues. They were field tested by 17 general practitioners with 119 dementia patients.

RESULTS

There was a high prevalence of comorbidity in the patients and frequent psychosocial issues in their management that were often not addressed. The guidelines were rated as very helpful for at least one aspect of care for 50% of the patients.

DISCUSSION

The guidelines were found to be useful to GPs.

Diagnosing dementia in primary care: the accuracy of informant reports

In the diagnosis of dementia, information obtained from informants or proxies is important; however, little is known about the circumstances under which informants' reports lack accuracy. This study compares informant reports of cognitive status against psychometric tests to identify the degree of, and factors associated with, discrepant reporting. Four areas of patient cognitive ability were examined: memory of recent events, ability to remember a short list of items after a delay, language/naming abilities, and working memory. Primary care practitioners recruited 248 community-dwelling patients aged 75 years or more or aged 50-74 years with suspected memory complaints; 248 friends or relatives acted as informants. More than half of the informants (60%) gave responses consistent with psychometric testing. Informants who underreported patient difficulties tended to report on patients who were diagnosed as having subclinical dementia, were less educated, and had poorer remote memory. Informants who overreported difficulties were more likely to report on those diagnosed with dementia. While informant accounts are critical for the assessment of dementia, we found that in 40% of cases these reports may be inaccurate, particularly when the patient has low education and poor remote memory or when overall cognitive difficulties are mild.