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Bucalossi J, Missirlian M, Moreau P, Samaille F, Tsitrone E, van Houtte D, Batal T, Bourdelle C, Chantant M, Corre Y, Courtois X, Delpech L, Doceul L, Douai D, Dougnac H, Faïsse F, Fenzi C, Ferlay F, Firdaouss M, Gargiulo L, Garin P, Gil C, Grosman A, Guilhem D, Gunn J, Hernandez C, Keller D, Larroque S, Leroux F, Lipa M, Lotte P, Martinez A, Meyer O, Micolon F, Mollard P, Nardon E, Nouailletas R, Pilia A, Richou M, Salasca S, Travère JM. The WEST project: Testing ITER divertor high heat flux component technology in a steady state tokamak environment. FUSION ENGINEERING AND DESIGN 2014. [DOI: 10.1016/j.fusengdes.2014.01.062] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Missirlian M, Bucalossi J, Corre Y, Ferlay F, Firdaouss M, Garin P, Grosman A, Guilhem D, Gunn J, Languille P, Lipa M, Richou M, Tsitrone E. The WEST project: Current status of the ITER-like tungsten divertor. FUSION ENGINEERING AND DESIGN 2014. [DOI: 10.1016/j.fusengdes.2014.01.050] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Gunn J, Palmer V. Visions of generalism - what does the future hold? AUSTRALIAN FAMILY PHYSICIAN 2014; 43:649-651. [PMID: 25225653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Support for generalism is underpinned by more than 100 years of writings and these writings point to writers and thinkers who have grappled with the tensions between generalism and specialism since ancient Egyptian times. Taking a historical stance we make the case that generalism is here to stay. But, what does the future hold? We outline some ideas for growing generalism in the wake of smart technologies, personalised medicine and the deluge of ever increasing health information.
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Lycett K, Wittert G, Gunn J, Hutton C, Clifford SA, Wake M. The challenges of real-world implementation of web-based shared care software: the HopSCOTCH Shared-Care Obesity Trial in Children. BMC Med Inform Decis Mak 2014; 14:61. [PMID: 25056431 PMCID: PMC4115470 DOI: 10.1186/1472-6947-14-61] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 07/18/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND E-health initiatives hold promise to improve shared-care models of health care. In 2008-2011 we developed and trialled web-based software to facilitate a randomised trial of a shared-care approach for childhood obesity involving General Practitioners (GPs) working with tertiary specialists. We describe the software's development, implementation and evaluation, and make recommendations for future e-health initiatives. The web-based software was designed with the goals of allowing both GPs and specialists to communicate and review patient progress; integrating with existing GP software; and supporting GPs to deliver the structured intervention. Specifically, we aimed to highlight the challenges inherent in this process, and report on the extent to which the software ultimately met its implementation and user aims. METHODS The study was conducted at the Royal Children's Hospital and 22 general practices across Melbourne, Australia. Participants comprised 30 GPs delivering the shared-care intervention. Outcomes included the following. (1) GPs' pre-specified software requirements: transcribed from two focus groups and analysed for themes using content analysis. (2) Software implementation and performance based on the experience of the research team and GPs. (3) GP users' evaluation collected via questionnaire. (4) Software usage collected via GP questionnaire and qualified through visual inspection of the software meta-data. RESULTS Software implementation posed difficult and at times disabling technological barriers (e.g. out-dated hardware, poor internet connections). The software's speed and inability to seamlessly link with day-to-day software was a source of considerable frustration. Overall, GPs rated software usability as poor, although most (68%) felt that the structure and functionality of the software was useful. Recommendations for future e-health initiatives include thorough scoping of IT systems and server speed, testing across diverse environments, automated pre-requisite checks and upgrades of processors/memory where necessary, and user-created usernames and passwords. CONCLUSIONS GPs are willing to embrace novel technologies to support their practice. However, implementation remains challenging mainly for technical reasons, and this precludes further evaluation of potential user-specific barriers. These findings could inform future e-health ventures into shared-care, and highlight the need for an appropriate infrastructure. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN126080000553.
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Dowsey MM, Gunn J, Choong PFM. Selecting those to refer for joint replacement: who will likely benefit and who will not? Best Pract Res Clin Rheumatol 2014; 28:157-71. [PMID: 24792950 DOI: 10.1016/j.berh.2014.01.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Osteoarthritis (OA) is one of the 10 most disabling diseases in developed countries and worldwide estimates are that 10% of men and 18% of women aged over 60 years have symptomatic OA, including moderate and severe forms. Total joint replacement (TJR) is considered the most effective treatment for end-stage OA in those who have exhausted available conservative interventions. The demand for TJR is continually rising due to the ageing population; in the United States, more than 1 million TJRs were performed in 2010 and the number of procedures is projected to exceed 4 million in the US by 2030. It has been estimated that of all hip and knee replacements performed, approximately one quarter of the patients may be considered inappropriate candidates. Predicting who will benefit from TJR and who will not would seem critical in terms of containing the current and projected expenditure as well as improving satisfaction in TJR recipients. Few formal predictive tools are available to aid referring clinicians to determine those likely to be good or poor responders to surgery and current available tools tend to focus on disease severity alone with little consideration of risk factors that may predict a poor outcome or impede an effective response to surgery. This review examines the tools available to assist with assessing appropriateness for TJR; investigates the modifiable risk factors associated with poor outcome; and identifies areas for future research in selecting those appropriate for joint replacement.
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Hsiao S, Tovar-Lopez FJ, Gunn J, Spencer T, Halliday I, Perrault C, Evans PC. 292Endothelial cell forward migration in a disturbed wall shear stress environment is promoted by ROCK inhibition. Cardiovasc Res 2014. [DOI: 10.1093/cvr/cvu087.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Pirotta M, Densley K, Forsdike K, Carter M, Gunn J. St John's wort use in Australian general practice patients with depressive symptoms: their characteristics and use of other health services. BMC COMPLEMENTARY AND ALTERNATIVE MEDICINE 2014; 14:204. [PMID: 24969102 PMCID: PMC4082422 DOI: 10.1186/1472-6882-14-204] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 06/23/2014] [Indexed: 11/17/2022]
Abstract
Background While depression is frequently managed by general practitioners, often patients self-manage these symptoms with alternative therapies, including St John’s wort (SJW). We tested whether use of SJW was associated with different patterns of conventional and complementary health service use, strategies used for management of depression, or user dissatisfaction with or lack of trust in their general practitioner or clinic overall. Methods Secondary analysis of data collected from an Australian population screened for a longitudinal cohort study of depression. Main outcome measures were CES-D for depressive symptoms, satisfaction with their general practitioner (GPAQ), Trust in Physician scale, self-report of health services usage and strategies used to manage depression, stress or worries. Results Response rate was 7667/17,780 (43.1%). Of these, 4.3% (320/7,432) had used SJW in the past 12 months (recent ‘SJW users’). SJW users were significantly more likely to be depressed and to have a higher CES-D score. There were no statistically significant differences between recent SJW users and non-SJW users in satisfaction with their general practice or in trust in their general practitioner (GP) when adjusted for multiple factors. SJW users were significantly more likely to use all health services, whether conventional or complementary, as well as other strategies used for mental health care. SJW users were also more likely to consider themselves the main carer for their depression. Conclusions Primary care attendees with symptoms of depression who use SJW appear not to be rejecting conventional medicine. Rather, they may be proactive care seekers who try both conventional and complementary strategies to manage their depressive symptoms. If GPs enquire and find that their depressed patients are using SJW, this may indicate that they might explore for unrelieved symptoms of depression and also consider the issue of potential for interactions between SJW and other medicines.
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Griffiths FE, Boardman FK, Chondros P, Dowrick CF, Densley K, Hegarty KL, Gunn J. The effect of strategies of personal resilience on depression recovery in an Australian cohort: A mixed methods study. Health (London) 2014; 19:86-106. [DOI: 10.1177/1363459314539774] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Strategies of personal resilience enable successful adaptation in adversity. Among patients experiencing depression symptoms, we explored which personal resilience strategies they find most helpful and tested the hypothesis that use of these strategies improves depression recovery. We used interview and survey data from the Diagnosis, Management and Outcomes of Depression in Primary Care 2005 cohort of patients experiencing depression symptoms in Victoria, Australia. A total of 564 participants answered a computer-assisted telephone interview question at 12 months follow-up, about what they found most helpful for their depression, stress or worries. Depressive disorder and severity were measured at annual follow-up using the Composite International Diagnostic Interview and the Patient Health Questionnaire self-rating questionnaire. Using interview responses, we categorised participants as users or not of strategies of personal resilience, specifically, drawing primarily on expanding their own inner resources or pre-existing relationships: 316 (56%) were categorised as primarily users of personal resilience strategies. Of these, 193 (61%) reported expanding inner resources, 79 (25%) drawing on relationships and 44 (14%) reported both. There was no association between drawing on relationships and depression outcome. There was evidence supporting an association between expanding inner resources and depression outcome: 25 per cent of users having major depressive disorder 1 year later compared to 38 per cent of non-users (adjusted odds ratio: 0.59, confidence interval: 0.36–0.97). This is the first study to show improved outcome for depression for those who identify as most helpful the use of personal resilience strategies. The difference in outcome is important as expanding inner resources includes a range of low intensity, yet commonly available strategies.
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Killeen S, Souroullas P, Ho Tin H, Hunter IA, O'Grady H, Gunn J, Hartley JE. Outcomes of asymptomatic anastomotic leaks found on routine postoperative water-soluble enema following anterior resection for cancer. World J Surg 2014; 37:2700-4. [PMID: 23982778 DOI: 10.1007/s00268-013-2193-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The incidence and consequence of an anastomotic leak associated with low anterior resection for cancer mandates covering stoma in most cases. A water-soluble enema is often performed to assess anastomotic integrity prior to stoma reversal. The functional outcome following reversal in patients with occult radiologically detected leaks is poorly defined. The goal of the present study was to determine the functional outcome in patients with a radiologically detected anastomotic leak who subsequently underwent stoma reversal. METHODS This case control study used patients with and without radiologically detected occult anastomotic leak having undergone reversal of covering stomata. The study group was matched with controls for age, gender, procedure, tumor stage, and adjuvant/neoadjuvant therapy. Validated fecal incontinence quality of life (FIQL), Cleveland Clinic Fecal Incontinence Score (CCFIS), and the Memorial Sloan-Kettering Cancer Center (MSKCC) Bowel Function Index (BFI) were used. Patient satisfaction, medication use, and ancillary procedures prior to closure were also recorded. RESULTS Thirteen patients with radiologically detected occult anastomotic leaks and 13 matched controls were identified from a prospectively maintained database. The FIQL, CCFIS, and MSKCC BFI scores were significantly reduced in those with occult leaks. The mean number of radiological and surgical interventions was significantly greater in the patients with occult leaks. Antidiarrheal and bulking agent use, as well as patient satisfaction, were the same for both groups. Only one patient in the occult leak group would not undergo stoma reversal again. CONCLUSIONS Reversal of a defunctioning ileostomy in the presence of an occult radiological leak can be associated with poorer functional outcomes, but patient satisfaction is undiminished.
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Yeung AH, Temple-Smith M, Fairley CK, Vaisey AM, Guy R, Law MG, Low N, Bingham AL, Gunn J, Kaldor J, Donovan B, Hocking JS. Chlamydia prevalence in young attenders of rural and regional primary care services in Australia: a cross-sectional survey. Med J Aust 2014; 200:170-5. [PMID: 24528434 DOI: 10.5694/mja13.10729] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 10/25/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To estimate chlamydia prevalence among 16-29-year-olds attending general practice clinics in Australia. DESIGN, PARTICIPANTS AND SETTING A cross-sectional survey was conducted from May 2010 to December 2012. Sexually experienced 16-29-year-olds were recruited from 134 general practice clinics in 54 rural and regional towns in four states and in nine metropolitan clinics (consecutive patients were invited to participate). Participants completed a questionnaire and were tested for chlamydia. MAIN OUTCOME MEASURE Chlamydia prevalence. RESULTS Of 4284 participants, 197 tested positive for chlamydia (4.6%; 95% CI, 3.9%-5.3%). Prevalence was similar in men (5.2% [65/1257]; 95% CI, 3.9%-6.4%) and women (4.4% [132/3027]; 95% CI, 3.5%-5.2%) (P = 0.25) and high in those reporting genital symptoms or a partner with a sexually transmissible infection (STI) - 17.0% in men (8/47; 95% CI, 2.8%-31.2%); 9.5% in women (16/169; 95% CI, 5.1%-13.8%). Nearly three-quarters of cases (73.4% [130/177]) were diagnosed in asymptomatic patients attending for non-sexual health reasons, and 83.8% of all participants (3258/3890) had attended for non-sexual health reasons. Prevalence was slightly higher in participants from rural and regional areas (4.8% [179/3724]; 95% CI, 4.0%-5.6%) than those from metropolitan areas (3.1% [17/548]; 95% CI, 1.5%-4.7%) (P = 0.08). In multivariable analysis, increasing partner numbers in previous 12 months (adjusted odds ratio [AOR] for three or more partners, 5.11 [95% CI, 2.35-11.08]), chlamydia diagnosis in previous 12 months (AOR, 4.35 [95% CI, 1.52-12.41]) and inconsistent condom use with most recent partner (AOR, 2.90 [95% CI, 1.31-6.40]) were significantly associated with chlamydia in men. In women, increasing partner numbers in previous 12 months (AOR for two partners, 2.59 [95% CI, 1.59-4.23]; AOR for three or more partners, 3.58 [95% CI, 2.26-5.68]), chlamydia diagnosis in previous 12 months (AOR, 3.13 [95% CI, 1.62-6.06]) and age (AOR for 25-29-year-olds, 0.23 [95% CI, 0.12-0.44]) were associated with chlamydia. CONCLUSIONS Chlamydia prevalence is similar in young men and women attending general practice. Testing only those with genital symptoms or a partner with an STI would have missed three-quarters of cases. Most men and women are amenable to being tested in general practice, even in rural and regional areas.
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Hetrick S, Simmons M, Sanci LA, Gunn J. Primary care monitoring of depressive symptoms in young people. AUSTRALIAN FAMILY PHYSICIAN 2014; 43:147-150. [PMID: 24600679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Monitoring depressive symptoms and suicidality is essential in the management of depression in young people, yet routine monitoring is rare. This qualitative study sought to explore the experiences and beliefs of general practitioners about factors associated with monitoring youth depression in primary care settings. METHODS Two focus groups with general practitioners (n = 12) were audio-recorded, transcribed verbatim and analysed using thematic analysis. A semi-structured interview schedule was used. RESULTS In the primary care setting, monitoring was perceived as part of a continuum of care that begins with screening and diagnosis and as beneficial mostly in regards to informing treatment planning. Benefits and risks were reported, along with challenges and facilitators. DISCUSSION Monitoring youth depression in primary care settings is perceived as both beneficial and potentially risky. Monitoring tools need to inform treatment planning, be brief and fit within existing electronic software used by general practitioners.
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Small R, Watson L, Gunn J, Mitchell C, Brown S. Improving population-level maternal health: a hard nut to crack? Long term findings and reflections on a 16-community randomised trial in Australia to improve maternal emotional and physical health after birth [ISRCTN03464021]. PLoS One 2014; 9:e88457. [PMID: 24586327 PMCID: PMC3938427 DOI: 10.1371/journal.pone.0088457] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 12/27/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Community level interventions to improve maternal and child health have been supported and well evaluated in resource poor settings, but less so in developed countries. PRISM--Program of Resources, Information and Support for Mothers--was a primary care and community-based cluster-randomised trial in sixteen municipalities in Victoria, Australia, which aimed to reduce depression in mothers and improve their physical health. The aim of this paper is to report the longer term outcomes of PRISM and to reflect on lessons learned from this universal community intervention to improve maternal health. METHODS Maternal health outcome data in PRISM were collected by postal questionnaire at six months and two years. At two years, the main outcome measures included the Edinburgh Postnatal Depression Scale (EPDS) and the SF-36. Secondary outcome measures included the Experience of Motherhood Scale (EOM) and the Parenting Stress Index (PSI). A primary intention to treat analysis was conducted, adjusting for the randomisation by cluster. RESULTS 7,169/18,424 (39%) women responded to the postal questionnaire at two years -3,894 (40%) in the intervention arm and 3,275 (38%) in the comparison arm. Respondents were mostly representative on available population data comparisons. There were no differences in depression prevalence (EPDS≥13) between the intervention and comparison arms (13.4% vs 13.1%; ORadj = 1.06, 95%CI 0.91-1.24). Nor did women's mental health (MCS: 48.6 vs 49.1) or physical health scores (PCS: 49.1 vs 49.0) on the SF-36 differ between the trial arms. CONCLUSION Improvement in maternal mental and physical health outcomes at the population level in the early years after childbirth remains a largely unmet challenge. Despite the lack of effectiveness of PRISM intervention strategies, important lessons about systems change, sustained investment and contextual understanding of the workability of intervention strategies can be drawn from the experience of PRISM. Trial Registration. Controlled-Trials.com ISRCTN03464021.
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Middleton A, Gunn J, Bassilios B, Pirkis J. Systematic review of research into frequent callers to crisis helplines. J Telemed Telecare 2014; 20:89-98. [DOI: 10.1177/1357633x14524156] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Summary We conducted a systematic review of research into callers making multiple calls to crisis helplines. Two databases were searched, identifying 561 articles from 1960 until 2012, of which 63 were relevant. Twenty-one articles from 19 separate studies presented empirical data about callers making multiple calls to crisis helplines. Of the 19 studies, three were intervention studies, five were surveys of callers and 11 were call record audits. Most studies were conducted in the USA and defined frequent callers as people making two or more calls. Frequent callers were more likely to be male and unmarried compared to other callers. There were no reported differences between frequent callers and other callers with regard to age, mental health conditions or suicidality. Three studies tested interventions designed to better manage frequent callers. These studies, even though small, reported reductions in the number of calls made by frequent callers. Suggested techniques for responding to frequent callers included: limiting the number and duration of calls allowed, assigning a specific counsellor, implementing face to face contact, the service initiating contact with the caller instead of waiting for callers to contact the service, providing short term anxiety and depression treatment programmes by telephone, and creating a specific management plan for each frequent caller. Future work requires robust study design methods using larger sample sizes and validated measurements.
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Caputo M, Chiastra C, Cianciolo C, Cutrì E, Dubini G, Gunn J, Keller B, Migliavacca F, Zunino P. Simulation of oxygen transfer in stented arteries and correlation with in-stent restenosis. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2013; 29:1373-1387. [PMID: 23996860 DOI: 10.1002/cnm.2588] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 07/10/2013] [Accepted: 07/20/2013] [Indexed: 06/02/2023]
Abstract
Computational models are used to study the combined effect of biomechanical and biochemical factors on coronary in-stent restenosis, which is a postoperative remodeling and regrowth pathology of the stented arteries. More precisely, we address numerical simulations, on the basis of Navier-Stokes and mass transport equations, to study the role of perturbed wall shear stresses and reduced oxygen concentration in a geometrical model reconstructed from a real porcine artery treated with a stent. Joining in vivo and in silico tools of investigation has multiple benefits in this case. On one hand, the geometry of the arterial wall and of the stent closely correspond to a real implanted configuration. On the other hand, the inspection of histological tissue samples informs us on the location and intensity of in-stent restenosis. As a result, we are able to correlate geometrical factors, such as the axial variation of the artery diameter and its curvature; the numerical quantification of biochemical stimuli, such as wall shear stresses; and the availability of oxygen to the inner layers of the artery, with the appearance of in-stent restenosis. This study shows that the perturbation of the vessel curvature could induce hemodynamic conditions that stimulate undesired arterial remodeling.
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Reeve J, Dowrick CF, Freeman GK, Gunn J, Mair F, May C, Mercer S, Palmer V, Howe A, Irving G, Shiner A, Watson J. Examining the practice of generalist expertise: a qualitative study identifying constraints and solutions. JRSM SHORT REPORTS 2013; 4:2042533313510155. [PMID: 24475347 PMCID: PMC3899736 DOI: 10.1177/2042533313510155] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Objectives Provision of person-centred generalist care is a core component of quality
primary care systems. The World Health Organisation believes that a lack of
generalist primary care is contributing to inefficiency, ineffectiveness and
inequity in healthcare. In UK primary care, General Practitioners (GPs) are
the largest group of practising generalists. Yet GPs fulfil multiple roles
and the pressures of delivering these roles along with wider contextual
changes create real challenges to generalist practice. Our study aimed to
explore GP perceptions of enablers and constraints for expert generalist
care, in order to identify what is needed to ensure health systems are
designed to support the generalist role. Design Qualitative study in General Practice. Setting UK primary care. Main outcome measures A qualitative study – interviews, surveys and focus groups with GPs and GP
trainees. Data collection and analysis was informed by Normalisation Process
Theory. Design and setting Qualitative study in General Practice. We conducted interviews, surveys and
focus groups with GPs and GP trainees based mainly, but not exclusively, in
the UK. Data collection and analysis were informed by Normalization Process
Theory. Participants UK based GPs (interview and surveys); European GP trainees (focus
groups). Results Our findings highlight key gaps in current training and service design which
may limit development and implementation of expert generalist practice
(EGP). These include the lack of a consistent and universal understanding of
the distinct expertise of EGP, competing priorities inhibiting the delivery
of EGP, lack of the consistent development of skills in interpretive
practice and a lack of resources for monitoring EGP. Conclusions We describe four areas for change: Translating EGP, Priority setting for EGP,
Trusting EGP and Identifying the impact of EGP. We outline proposals for
work needed in each area to help enhance the expert generalist role.
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French SD, Densley K, Charity MJ, Gunn J. Who uses Australian chiropractic services? Chiropr Man Therap 2013; 21:31. [PMID: 24295295 PMCID: PMC3849188 DOI: 10.1186/2045-709x-21-31] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 08/30/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of chiropractic services is widespread, however, little is known about the characteristics of people who seek chiropractic care in Australia. This study compared the characteristics of users and non-users of chiropractic services from a cohort of patients sourced from general medical practice in Victoria, Australia. METHODS This is a secondary analysis of baseline screening data from a prospective adult cohort study beginning in 2005. Thirty randomly selected Australian general medical practices mailed out surveys to 17,780 of their patients. Differences were examined between chiropractic users and others, and between chiropractic users who reported a back problem to those who did not. RESULTS Of 7,519 respondents, 15% indicated they had visited a chiropractor in the last 12 months. Chiropractic users were more likely to have their GP located in a rural location and to be born in Australia; they were less likely to be in the older age group (55-76), to be unemployed or to have a pension/benefit as their main source of income. Chiropractic users were more likely to: have a back problem; use complementary or alternative medication; visit another type of complementary health practitioner or a physiotherapist. They were less likely to take medication for certain health problems (e.g. for high blood pressure, high cholesterol or asthma). No important differences were seen between chiropractic users and non-users for other health problems. People who visited a chiropractor and reported a back problem were more likely to: be a current smoker; have a number of other chronic conditions, including arthritis, hypertension, chronic sinusitis, asthma, dermatitis, depression and anxiety; report taking medications, including antidepressants, analgesics (painkillers and arthritis medication) and complementary or alternative medications. CONCLUSIONS This large cross-sectional study of general medical practice attendees suggests that chiropractors are the most commonly consulted complementary health profession. Chiropractors should ensure they are aware of their patients' health conditions other than musculoskeletal problems and should ensure they are appropriately managed.
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Moretti C, Fenning S, Parviz Y, Gunn J, D'Ascenzo F, Giusto F, Gaita F, Lane N, Iqbal J, Denvir M. Frailty assessment as a prognostic tool in elderly acute coronary syndrome patients to identify those approaching end-of-life: results from prospective multicenter fate-acs study. Eur Heart J 2013. [DOI: 10.1093/eurheartj/eht309.p3083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Hegarty K, O'Doherty L, Taft A, Chondros P, Brown S, Valpied J, Astbury J, Taket A, Gold L, Feder G, Gunn J. Screening and counselling in the primary care setting for women who have experienced intimate partner violence (WEAVE): a cluster randomised controlled trial. Lancet 2013; 382:249-58. [PMID: 23598181 DOI: 10.1016/s0140-6736(13)60052-5] [Citation(s) in RCA: 137] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Evidence for a benefit of interventions to help women who screen positive for intimate partner violence (IPV) in health-care settings is limited. We assessed whether brief counselling from family doctors trained to respond to women identified through IPV screening would increase women's quality of life, safety planning and behaviour, and mental health. METHODS In this cluster randomised controlled trial, we enrolled family doctors from clinics in Victoria, Australia, and their female patients (aged 16-50 years) who screened positive for fear of a partner in past 12 months in a health and lifestyle survey. The study intervention consisted of the following: training of doctors, notification to doctors of women screening positive for fear of a partner, and invitation to women for one-to-six sessions of counselling for relationship and emotional issues. We used a computer-generated randomisation sequence to allocate doctors to control (standard care) or intervention, stratified by location of each doctor's practice (urban vs rural), with random permuted block sizes of two and four within each stratum. Data were collected by postal survey at baseline and at 6 months and 12 months post-invitation (2008-11). Researchers were masked to treatment allocation, but women and doctors enrolled into the trial were not. Primary outcomes were quality of life (WHO Quality of Life-BREF), safety planning and behaviour, mental health (SF-12) at 12 months. Secondary outcomes included depression and anxiety (Hospital Anxiety and Depression Scale; cut-off ≥8); women's report of an inquiry from their doctor about the safety of them and their children; and comfort to discuss fear with their doctor (five-point Likert scale). Analyses were by intention to treat, accounting for missing data, and estimates reported were adjusted for doctor location and outcome scores at baseline. This trial is registered with the Australian New Zealand Clinical Trial Registry, number ACTRN12608000032358. FINDINGS We randomly allocated 52 doctors (and 272 women who were eligible for inclusion and returned their baseline survey) to either intervention (25 doctors, 137 women) or control (27 doctors, 135 women). 96 (70%) of 137 women in the intervention group (seeing 23 doctors) and 100 (74%) of 135 women in the control group (seeing 26 doctors) completed 12 month follow-up. We detected no difference in quality of life, safety planning and behaviour, or mental health SF-12 at 12 months. For secondary outcomes, we detected no between-group difference in anxiety at 12 months or comfort to discuss fear at 6 months, but depressiveness caseness at 12 months was improved in the intervention group compared with the control group (odds ratio 0·3, 0·1-0·7; p=0·005), as was doctor enquiry at 6 months about women's safety (5·1, 1·9-14·0; p=0·002) and children's safety (5·5, 1·6-19·0; p=0·008). We recorded no adverse events. INTERPRETATION Our findings can inform further research on brief counselling for women disclosing intimate partner violence in primary care settings, but do not lend support to the use of postal screening in the identification of those patients. However, we suggest that family doctors should be trained to ask about the safety of women and children, and to provide supportive counselling for women experiencing abuse, because our findings suggest that, although we detected no improvement in quality of life, counselling can reduce depressive symptoms. FUNDING Australian National Health and Medical Research Council.
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Walker J, Walker S, Fairley CK, Bilardi J, Chen MY, Bradshaw CS, Urban E, Pirotta M, Birden H, Donovan B, Kaldor JM, Gunn J, Hocking JS. What do young women think about having a chlamydia test? Views of women who tested positive compared with women who tested negative. Sex Health 2013; 10:39-42. [PMID: 23158366 DOI: 10.1071/sh12019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 06/26/2012] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine young women's experience of having a chlamydia (Chlamydia trachomatis) test as part of a chlamydia incidence study, and to determine how women who tested positive during the study experienced having a test compared with the experience of women who always tested negative. METHODS Women in an Australian chlamydia incidence study were tested at 3- to 6-monthly intervals during a 12-month period. At the final stage of the study, the women completed a questionnaire about how they felt about testing positive or how they anticipated they might feel about testing positive if they only tested negative. Questions about future sexual behaviour and testing were included. RESULTS The questionnaire was completed by 872 out of 1116 (78%) women, including 67 women who tested positive. Many women (75%) felt anxious when having a chlamydia test but women who tested positive were less concerned about their future health (61% v. 81%, P<0.01), were less concerned about their partner's reactions (62% v. 79%, P<0.01) and were more likely to discuss their diagnosis with other people (57% v. 36%, P<0.01). CONCLUSIONS The participants in the study were pleased to have been tested and supported a screening program. Women who tested positive were less concerned about having a positive result than women who tested negative anticipated they might be. IMPLICATIONS Clinicians need to be aware that having a chlamydia test can cause anxiety in young women and for a screening program to be successful, this must be addressed.
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Hegarty KL, O'Doherty LO, Astbury J, Gunn J. Identifying intimate partner violence when screening for health and lifestyle issues among women attending general practice. Aust J Prim Health 2013; 18:327-31. [PMID: 22950858 DOI: 10.1071/py11101] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Accepted: 11/29/2011] [Indexed: 11/23/2022]
Abstract
Intimate partner violence is a common but under-recognised issue for women attending primary care. There is a lack of studies looking at women's comfort to discuss and openness to getting help for health issues, including fear of a partner, in primary care. Female patients (aged 16-50 years) attending 55 general practitioners (GPs) in Victoria, Australia were mailed a brief survey that screened for health and lifestyle issues, comfort to discuss these issues and intention to get help in primary care. Needing physical activity and smoking were the issues women were most comfortable to discuss; followed by difficulty controlling what and/or how much is eaten, feeling down, depressed, hopeless or worried, and use of drugs or alcohol. Women were least comfortable to discuss fear of a partner and least likely to seek help for it from the GP or primary care nurse. However, as with the other issues, acceptability of being asked in a survey was high. All health and lifestyle issues predicted fear of a partner. Primary care practitioners should be aware of this complex major public health issue especially when carrying out preventive health care.
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Roth AM, Hensel DJ, Gunn J, Fortenberry JD, Garfein R, Arno JN, Wiehe SE. P4.037 Use of Cell Phone Diaries to Understand Risk Contexts of Sexual Events Among Female Sex Workers. Br J Vener Dis 2013. [DOI: 10.1136/sextrans-2013-051184.0935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Hocking J, Temple-Smith M, Guy R, Kong F, Low N, Donovan B, Law M, Kaldor J, Gunn J, Fairley C. P5.017 The Australian Chlamydia Control Effectiveness Pilot (ACCEPt): Early Results from a Randomised Trial of Annual Chlamydia Screening in General Practise. Br J Vener Dis 2013. [DOI: 10.1136/sextrans-2013-051184.1062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Wake M, Lycett K, Clifford SA, Sabin MA, Gunn J, Gibbons K, Hutton C, McCallum Z, Arnup SJ, Wittert G. Shared care obesity management in 3-10 year old children: 12 month outcomes of HopSCOTCH randomised trial. BMJ 2013; 346:f3092. [PMID: 23751902 PMCID: PMC3677741 DOI: 10.1136/bmj.f3092] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To determine whether general practice surveillance for childhood obesity, followed by obesity management across primary and tertiary care settings using a shared care model, improves body mass index and related outcomes in obese children aged 3-10 years. DESIGN Randomised controlled trial. SETTING 22 family practices (35 participating general practitioners) and a tertiary weight management service (three paediatricians, two dietitians) in Melbourne, Australia. PARTICIPANTS Children aged 3-10 years with body mass index above the 95th centile recruited through their general practice between July 2009 and April 2010. INTERVENTION Children were randomly allocated to one tertiary appointment followed by up to 11 general practice consultations over one year, supported by shared care, web based software (intervention) or "usual care" (control). Researchers collecting outcome measurements, but not participants, were blinded to group assignment. MAIN OUTCOME MEASURES Children's body mass index z score (primary outcome), body fat percentage, waist circumference, physical activity, quality of diet, health related quality of life, self esteem, and body dissatisfaction and parents' body mass index (all 15 months post-enrolment). RESULTS 118 (60 intervention, 56 control) children were recruited and 107 (91%) were retained and analysed (56 intervention, 51 control). All retained intervention children attended the tertiary appointment and their general practitioner for at least one (mean 3.5 (SD 2.5, range 1-11)) weight management consultation. At outcome, children in the two trial arms had similar body mass index (adjusted mean difference -0.1 (95% confidence interval -0.7 to 0.5; P=0.7)) and body mass index z score (-0.05 (-0.14 to 0.03); P=0.2). Similarly, no evidence was found of benefit or harm on any secondary outcome. Outcomes varied widely in the combined cohort (mean change in body mass index z score -0.20 (SD 0.25, range -0.97-0.47); 26% of children resolved from obese to overweight and 2% to normal weight. CONCLUSIONS Although feasible, not harmful, and highly rated by both families and general practitioners, the shared care model of primary and tertiary care management did not lead to better body mass index or other outcomes for the intervention group compared with the control group. Improvements in body mass index in both groups highlight the value of untreated controls when determining efficacy. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12608000055303.
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Gunn J, Elliott P, Densley K, Middleton A, Ambresin G, Dowrick C, Herrman H, Hegarty K, Gilchrist G, Griffiths F. A trajectory-based approach to understand the factors associated with persistent depressive symptoms in primary care. J Affect Disord 2013; 148:338-46. [PMID: 23375580 DOI: 10.1016/j.jad.2012.12.021] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 12/24/2012] [Accepted: 12/24/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Depression screening in primary care yields high numbers. Knowledge of how depressive symptoms change over time is limited, making decisions about type, intensity, frequency and length of treatment and follow-up difficult. This study is aimed to identify depressive symptom trajectories and associated socio-demographic, co-morbidity, health service use and treatment factors to inform clinical care. METHODS 789 people scoring 16 or more on the CES-D recruited from 30 randomly selected Australian family practices. Depressive symptoms are measured using PHQ-9 at 3, 6, 9 and 12 months. RESULTS Growth mixture modelling identified a five-class trajectory model as the best fitting (lowest Bayesian Information Criterion): three groups were static (mild (n=532), moderate (n=138) and severe (n=69)) and two were dynamic (decreasing severity (n=32) and increasing severity (n=18)). The mild symptom trajectory was the most common (n=532). The severe symptom trajectory group (n=69) differed significantly from the mild symptom trajectory group on most variables. The severe and moderate groups were characterised by high levels of disadvantage, abuse, morbidity and disability. Decreasing and increasing severity trajectory classes were similar on most variables. LIMITATIONS Adult only cohort, self-report measures. CONCLUSIONS Most symptom trajectories remained static, suggesting that depression, as it presents in primary care, is not always an episodic disorder. The findings indicate future directions for building prognostic models to distinguish those who are likely to have a mild course from those who are likely to follow more severe trajectories. Determining appropriate clinical responses based upon a likely depression course requires further research.
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