General practitioners' experiences of being involved in local public health work in Norway. A qualitative study

AIM

The aim was to explore how general practitioners experienced being involved in local public health work and how they worked with prevention and health promotion clinically after the introduction of the Public Health Act in 2012.

DESIGN, SETTING AND SUBJECTS

Qualitative study with focus groups interviews with 18 GPs from different municipalities in Norway.

RESULTS

The GPs said that they either had not at all or only to a limited extent been involved in local public health work in their municipalities. They reported finding it hard to prioritize individual disease prevention and health promotion in their clinical work. GPs thought of health promotion as something that mainly concerned healthy people at a group level.

CONCLUSIONS

Based on the experiences of the GPs in this study, there is a gap between governmental expectations to the role of GPs in public health, and how it works in practice.KEY POINTSWith the Norwegian Public Health Act launched in 2012, GPs were expected to contribute to better population health in their clinical work and as data providers to local public health surveillance.The GPs interviewed in this study said they had not been involved in local public health work, and they found it hard to give disease prevention and health promotion priority in their clinical work.GPs expressed various perceptions of what prevention and health promotion entails.

GDF-15 Neutralization Alleviates Platinum-Based Chemotherapy-Induced Emesis, Anorexia, and Weight Loss in Mice and Nonhuman Primates

Platinum-based cancer therapy is restricted by dose-limiting side effects and is associated with elevation of growth differentiation factor 15 (GDF-15). But whether this elevation contributes to such side effects has been unclear. Here, we explored the effects of GDF-15 blockade on platinum-based chemotherapy-induced emesis, anorexia, and weight loss in mice and/or nonhuman primate models. We found that circulating GDF-15 is higher in subjects with cancer receiving platinum-based chemotherapy and is positively associated with weight loss in colorectal cancer (NCT00609622). Further, chemotherapy agents associated with high clinical emetic score induce circulating GDF-15 and weight loss in mice. Platinum-based treatment-induced anorexia and weight loss are attenuated in GDF-15 knockout mice, while GDF-15 neutralization with the monoclonal antibody mAB1 improves survival. In nonhuman primates, mAB1 treatment attenuates anorexia and emesis. These results suggest that GDF-15 neutralization is a potential therapeutic approach to alleviate chemotherapy-induced side effects and improve the quality of life.

Abstract 3056: Growth differentiation factor 15 (GDF-15) inhibition attenuates platinum-based chemotherapy-induced emesis, anorexia and weight loss and increases survival

Platinum-based chemotherapy is associated with nausea/emesis, anorexia and weight loss which reduce patient quality of life and limit treatment adherence potentially leading to poor treatment outcomes. Cisplatin increases circulating growth differentiation factor 15 (GDF-15), a cytokine that induces conditioned taste aversion, anorexia and weight loss in preclinical models. GDF-15 signals through the hindbrain receptor glial cell-derived neurotrophic factor receptor alpha-like (GFRAL). Cisplatin-induced anorexia/weight loss was attenuated in a GFRAL knockout mouse; therefore, we examined whether GDF-15 inhibition can prevent platinum-based chemotherapy-induced emesis, anorexia and weight loss, and also increase survival using mouse and/or nonhuman primate models. In cancer patients, platinum treatment increased circulating GDF-15 in non small cell lung carcinoma, colorectal, and ovarian cancer (~1.5 fold) compared to those receiving a non-platinum-based therapy. Furthermore, cisplatin, oxaliplatin and carboplatin administered individually all increased circulating GDF-15 in wildtype mice (≥ 5 fold) and induced anorexia, skeletal muscle wasting, and weight loss. GDF-15 mRNA was increased in kidney, liver, brain and white adipose tissue. These effects were prevented in GDF-15 knockout mice, however only a partial blockade was observed in the carboplatin group. In nonhuman primates, cisplatin treatment for 5 days (96% of the daily recommended clinical dose) also increased circulating GDF-15 (> 5 fold), and induced anorexia and emesis. Treatment with the anti-GDF-15 monoclonal antibody (mAB1) resulted in no detectable circulating levels of free GDF-15, and attenuated both cisplatin-induced anorexia and emesis. Furthermore, in a mouse cachectic tumor model (subcutaneous implantation of tumor tissue derived from human non-small cell lung carcinoma adenocarcinoma), cisplatin treatment inhibited tumor growth; however, GDF-15 levels were still elevated and additional weight loss occurred compared to vehicle control. When mAB1 was given in combination with cisplatin, weight loss was reversed and tumor growth inhibition was maintained, resulting in greater survival compared to cisplatin alone. Taken together, these data support the notion that GDF-15 inhibition with mAB1 holds the potential as an effective therapeutic approach to alleviate GDF-15 mediated emesis, anorexia and weight loss with the aim to enable optimal cancer treatment as well as to improve patient quality of life and potentially survival.

Citation Format: Danna M. Breen, Kevin Beaumont, Donald Bennett, Julia Brosnan, Roberto Calle, Jeffrey R. Chabot, Susie Collins, Teresa Cunio, Ryan M. Esquejo, Stephanie Joaquim, Alison Joyce, Hanna Kim, Laura Lin, Betty Pettersen, Shuxi Qiao, Michelle Rossulek, Brendan Tierney, Karen M. Walters, Gregory Weber, Zhidan Wu, Bei B. Zhang, Morris J. Birnbaum. Growth differentiation factor 15 (GDF-15) inhibition attenuates platinum-based chemotherapy-induced emesis, anorexia and weight loss and increases survival [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 3056.

Discovery of cyclopropyl chromane-derived pyridopyrazine-1,6-dione γ-secretase modulators with robust central efficacy

Herein we describe the discovery of a novel series of cyclopropyl chromane-derived pyridopyrazine-1,6-dione γ-secretase modulators for the treatment of Alzheimer's disease (AD). Using ligand-based design tactics such as conformational analysis and molecular modeling, a cyclopropyl chromane unit was identified as a suitable heterocyclic replacement for a naphthyl moiety that was present in the preliminary lead 4. The optimized lead molecule 44 achieved good central exposure resulting in robust and sustained reduction of brain amyloid-β42 (Aβ42) when dosed orally at 10 mg kg-1 in a rat time-course study. Application of the unpaced isolated heart Langendorff model enabled efficient differentiation of compounds with respect to cardiovascular safety, highlighting how minor structural changes can greatly impact the safety profile within a series of compounds.

[Physicians' experience with and attitudes to interaction between health care levels]

BACKGROUND

We have studied physicians' experience with and attitudes to interaction between health care levels, and their opinions on how this can be improved.

MATERIAL AND METHODS

Three focus groups were established. They consisted of 15 male and 2 female physicians with 3 months to 28 years of experience. Interviews with the participants were transcribed and qualitatively analysed.

RESULTS

Physicians had different opinions on which characteristics are important to establish a good professional interaction, and their opinions varied according to which health care level they represent. While GPs emphasised confidence, respect, knowledge of each other and accessibility, that is a relational perspective; the local hospital physicians put more emphasis on capacity, i.e. competence, stability and accessibility. Physicians at the central Hospital emphasized capacity and structure, i.e. their own and collaborators' professional interest, accessibility and formalised structures for interactions. A sense of personal knowledge and verbal and written contact was important, but guidelines and treatment plans were also considered to be important for interaction. There was a strong ownership to the individual patient across all three levels, which was an unexpected finding.

CONCLUSIONS

Good interaction seems to be a balance between the relational perspective, with emphasis on dialogue, structural arrangements, accessibility and continuity and professional competence. In addition, there is a need to clarify responsibilities for each patient.

[Infusion of barbiturates as a compenent in the treatment of refractory pain in patients with terminal cancer]

Four patients with advanced cancer were referred to the Pain Team because of refractory pain symptoms. They received intravenous barbiturates prior to death. All attempts at palliative treatment had been exhausted. The symptoms were described by patients and family as unendurable. After adding intravenous thiopental, relief and tranquility were achieved. All four patients died peacefully. The need to sedate to a state of unconsciousness or semi-consciousness to relieve symptoms in dying cancer patients is extremely rare. After all viable alternatives have been explored, titrated barbiturate infusion as an adjuvant may fill a void in the care of especially challenging patients as they approach death from terminal cancer.

[Complaints--a source of quality assurance even in primary health care]

In this article we discuss the handling of complaints from consumers of primary health care. We present data from municipalities on the frequency of complaints and the ways of handling them. In primary health care complaints are not handled systematically, and are seldom referred to in internal meetings. We conclude that complaints and other reactions from consumers should be used in quality control in primary health care.

Skin injury in an infant with pulse oximetry

An 11-month-old girl received 23 propofol anaesthetics for radiation treatment of a retinoblastoma. After the first two anaesthetics, a skin injury appeared on the pulp of the toes, where the light source of a pulse oximeter probe had been placed. During the remaining 21 anaesthetics the light source of the probe was placed over the nails, and no other skin lesions occurred. Examination of the equipment revealed no malfunction. Thermal and other possible causes of the skin injury are discussed.

Interpleural analgesia in the treatment of severe thoracic postherpetic neuralgia

Effective, long-lasting pain relief was produced in 26 patients suffering from severe thoracic postherpetic neuralgia by intermittent administration of local anesthetics into the pleural space through a percutaneously placed interpleural catheter. The duration of treatment varied from seven to 21 days. During this period, 30 ml of 0.5% bupivacaine with epinephrine (5 micrograms/ml) were injected every 24 hours. The injections were continued for three days after the patients were pain free or had reached an analgesic plateau. All patients achieved good to excellent pain relief. During a follow-up period of five to 15 months, their level of pain has not increased from the level achieved at the end of the treatment program.

Successful treatment of chronic pancreatitis pain with interpleural analgesia

Interpleural analgesia has recently been shown to be effective in the management of various chronic pain syndromes. We have used interpleural analgesia successfully in 11 patients with severe chronic pancreatitis of 24-38 months' duration. Daily injections of 30 ml of 0.5 per cent bupivacaine with epinephrine 5 mu.ml-1, were given through a percutaneously inserted pleural catheter over a five- to ten-day period. Patients have remained pain-free during follow up which ranges from 24 to 40 weeks. This method of providing analgesia for the patient suffering from the pain of chronic pancreatitis is simple, safe, effective and can be provided on an outpatient basis.