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Background: Early diagnosis and antibiotic therapy in patients with sepsis reduce morbidity and mortality, thus pre-hospital management is likely to affect patient outcomes. Pre-hospital administration may increase the risk of unnecessary use of broad-spectrum antibiotics, but identification of an infectious focus enables more targeted antibiotic therapy. The aim of this study was to investigate how paramedics, with or without the assistance of general practitioners, can administer empiric intravenous antibiotic treatment against sepsis in a timely manner. Methods: Cohort study of patients with suspected sepsis that received pre-hospital intravenous antibiotics and were transported to hospital. The setting was mainly rural with long average distance to hospital. Patients received targeted antibiotic treatment after an assessment based on clinical work-up supported by scoring systems. Patients were prospectively included from May 2018 to August 2022. Results are presented as median or absolute values, and chi-square tests were used to compare categorical data. Results: We included 328 patients. Median age was 76 years (IQR 64, 83) and 48.5% of patients were female. 30-days all-cause mortality was 10.4%. In cases where a suspected infectious focus was determined, the hospital discharge papers confirmed the pre-hospital diagnosis focus in 195 cases (79.3%). The presence of a general practitioner during the pre-hospital assessment increased the rate of correctly identified infectious focus from 72.6% to 86.1% (p = 0.009). Concordance between pre-hospital identification of a tentative focus and discharge diagnosis was highest for lower respiratory tract (p = 0.02) and urinary tract infections (p = 0.03). Antibiotic treatment was initiated 44 min (median) after arrival of ambulance, and median transportation time to hospital was 69 min. Antibiotic therapy was started 76 min (median) before arrival at hospital. Conclusions: Pre-hospital identification of infectious focus in suspected sepsis was feasible, and collaboration with primary care physicians increased level of diagnostic accuracy. This allowed initiation of intravenous focus-directed antibiotics more than one hour before arrival in hospital in a rural setting. The effect of pre-hospital therapy on timing was much stronger than in previous studies from more urban areas. [ABSTRACT FROM AUTHOR]

Background: Worldwide, mild traumatic brain injury, synonymous with concussion, affects more than 30–50 million each year. The incidence of concussion in Denmark is estimated to be about 20,000 yearly. Although complete resolution normally occurs within a few weeks, up to a third develop persistent post-concussion symptoms (PPCS) beyond 3 months. Evidence for effective treatment strategies is scarce. The objective of this study is to evaluate the efficacy of the novel intervention GAIN Lite added to enhanced usual care (EUC) for adults with mild-to-moderate PPCS compared to EUC only. Methods: An open-label, parallel-group, two-arm randomised controlled superiority trial (RCT) with 1:1 allocation ratio. Potential participants will be identified through the hospital's Business Intelligence portal of the Central Denmark Region or referred by general practitioners within 2–4 months post-concussion. Participants with mild-to-moderate PPCS will be randomly assigned to either (1) EUC or (2) GAIN Lite added to EUC. GAIN Lite is characterised as a complex intervention and has been developed, feasibility-tested and process evaluated before effect evaluation in the RCT. GAIN Lite contains an initial remote interview, self-administrated e-learning videos and voluntary remote counselling with an allocated occupational- or physiotherapist. Sixty-six participants will be recruited to each group. Primary outcomes are mean changes in PPCS and limitations in daily life from baseline to 24 weeks after baseline. Discussion: GAIN Lite is a low-intensity intervention for adults with mild-to-moderate PPCS. Offering a remote intervention may improve access to rehabilitation and prevent chronification for individuals with mild-to-moderate PPCS. Moreover, GAIN Lite will facilitate access to healthcare, especially for those with transportation barriers. Overall, GAIN Lite may provide an accessible, flexible and convenient way to receive treatment based on sound theories and previous evidence of effective interventions for adults with mild-to-moderate PPCS. Trial registration: ClinicalTrials.gov NCT05233475. Registered on February 10, 2022. [ABSTRACT FROM AUTHOR]

Background: At least 10% of Covid-19 recovered individuals experience persistent symptoms (Long Covid). Primary healthcare and general practitioners (GPs) are at the forefront in their care. In this study, GPs' knowledge, perceptions and experiences with Long Covid, and the definition used in two countries, are investigated to provide insight into GPs' care for Long Covid patients at a cross-country level. Methods: A cross-sectional study targeted towards GPs was conducted in Belgium and Malta during spring and early summer 2022. An online survey consisting of 15 questions on Long Covid was disseminated. Additionally, country-specific practice and demographic characteristics were collected. Descriptive and logistic regression analyses were performed. Results: A total of 150 GPs (Belgium = 105; Malta = 45) responded. Female GPs represented 58.0%, median age was 49 years (IQR: 37–61). Concerning GPs' knowledge and perception on Long Covid, in both countries, most GPs reported insufficient scientific knowledge and information on Long Covid diagnosis and treatment. Access to educational material was limited and an awareness-rising campaign on Long Covid was deemed necessary. Moreover, two out of three GPs stated that Long Covid patients were not well followed up by primary healthcare in mid-2022. For diagnosing Long Covid, 54.7% required a positive Covid-19 test, more often among Belgian GPs than Maltese (64.3% vs. 45.2%, p = 0.036). To assess Long Covid, GPs mainly applied diagnostic criteria by themselves (47.3%) in combination with persistent symptoms (4 weeks to 5 months). Most GPs had experience with Long Covid patients in their practice, regardless of practice type and GPs' country, sex or age (p = 0.353; p = 0.241; p = 0.194; p = 0.058). Although most GPs (94.7%) stated that Long Covid patients should follow multidisciplinary approach, 48.3% reported providing care for these patients themselves or with GP colleagues and only 29.8% by multidisciplinary cooperation. Conclusions: GPs frequently provide (multidisciplinary) care to Long Covid patients and GPs' care showed similarities at cross-country level. Although GPs perceive lack of scientific knowledge and educational material on Long Covid, similar diagnostic criteria among GPs were noted. Uniform evidence-based guidelines, scientific support and training for GP across Europe must be a priority to enhance their treatment approach to Long Covid. [ABSTRACT FROM AUTHOR]

Background: This study investigated the perceived barriers and potential facilitators for culturally sensitive care among general practitioners in Flanders. Understanding these dynamics is crucial for improving healthcare quality and equity. Methodology: Twenty-one in-depth interviews were conducted with Flemish GPs. Braun and Clarke's reflexive thematic analysis was employed to develop and interpret themes that elucidate shared underlying meanings and capture the nuanced challenges and strategies related to cultural sensitivity in healthcare. Results: Two core themes were generated: GPs' uncertainty and opposition. These themes manifest in emotional responses such as frustration, miscomprehension, and feelings of helplessness, influencing relational outcomes marked by patient disconnect and reduced motivation for cultural sensitivity. The barriers identified are exacerbated by resource scarcity and limited intercultural contact. Conversely, facilitators include structural elements like interpreters and individual strategies such as engagement, aimed at enhancing GPs' confidence in culturally diverse encounters. A meta-theme of perceived lack of control underscores the challenges, particularly regarding language barriers and resource constraints, highlighting the critical role of GPs' empowerment through enhanced intercultural communication skills. Conclusion: Addressing GPs' uncertainties and oppositions can mitigate related issues, thereby promoting comprehensive culturally sensitive care. Essential strategies include continuous education and policy reforms to dismantle structural barriers. Moreover, incentivizing culturally sensitive care through quality care financial incentives could bolster GP motivation. These insights are pivotal for stakeholders—practitioners, policymakers, and educators—committed to advancing culturally sensitive healthcare practices and, ultimately, for fostering more equitable care provision. [ABSTRACT FROM AUTHOR]

Background: Global research on gender bias has highlighted key trends in discrimination and inequality across various fields, including medicine. In Lebanon, a nation celebrated for its diverse cultural landscape and increasing female representation in medical education, there has been a notable absence of studies exploring gender dynamics in the medical profession. Methods: To address this gap, we conducted a cross-sectional study using an online survey to explore the Lebanese population's perceptions towards female physicians and the quality of care they provide. Results: The mean age of the study sample (n = 330) was 31.55 ± 10.07 years and included 114 females and 216 males. Most respondents had received care from a female physician. Notably, those who selected female physicians as their family doctors or had female doctors within their immediate family displayed a stronger tendency to engage in annual medical check-ups. While most respondents did not express any preference for the gender of their general practitioner or surgeon, there was a marked preference for female obstetricians/gynecologists, psychiatrists, pediatricians, and dermatologists. This preference was attributed to perceptions of female physicians being particularly compassionate, understanding, and proficient in communication. Conclusion: This study represents a groundbreaking contribution to understanding gender perceptions in the Lebanese medical field. It highlights the growing trust and positive regard for female physicians, underscoring the significant role in shaping healthcare experiences and outcomes in Lebanon. [ABSTRACT FROM AUTHOR]

Background: Chronic insomnia is a common yet often overlooked issue in primary health care. This study investigated the knowledge, attitude, and practices of chronic insomnia management among general practitioners (GPs). Methods: A cross-sectional online survey was conducted among GPs providing routine care to adults with insomnia in health facilities at all levels in Sichuan Province, China. Additionally, we designed an online questionnaire that included basic information and knowledge, attitudes, and practices regarding chronic insomnia management. Results: We included 420 GPs, 66.2% of whom were female and 58.1% were from community health service centers. Total 198 (47.1%) GPs had received specific training and only 2 GPs (0.5%) correctly answered the knowledge-related questions. Furthermore, only 44 GPs (10.5%) demonstrated excellent practice behaviors, while most GPs (70.2%) expressed high demand for training in insomnia management. Insomnia training experience was associated with higher practice scores (β = 3.318, p < 0.001). Conclusion: This study established an association and correlation between knowledge, attitude, and practice scores in treating insomnia and the sociodemographic characteristics of GPs in China. Although knowledge and practice performance in this field need to be improved, they mostly displayed a positive attitude towards insomnia management. Thus, offering continuing education opportunities to GPs would be highly beneficial. [ABSTRACT FROM AUTHOR]

Background: International clinical guidelines recommend that smoking, nutrition, alcohol consumption, physical activity and gestational weight gain (SNAP-W) be addressed as part of routine antenatal care throughout pregnancy. However, guideline recommendations are poorly implemented, and few antenatal care recipients routinely receive the recommended care. There is a need to establish the determinants (barriers and enablers) to care delivery to inform strategies to improve implementation. This systematic review aimed to synthesize qualitative and quantitative evidence of the barriers and enablers to the routine delivery of antenatal care targeting SNAP-W health risks. Methods: A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Seven databases were searched for relevant studies published between January 2001 and November 2023. Study findings were coded and analysed according to the domains of the Theoretical Domains Framework (TDF). Results: Forty-nine studies were included in the review, 27 qualitative studies and 22 quantitative studies. The studies were conducted in 14 countries. Data were collected from 7146 antenatal care providers (midwives, Aboriginal health workers, obstetricians, medical officers, general practitioners) and 352 barriers and enablers were identified. Across all SNAP-W health risk and antenatal care provider groups, the predominant TDF domain was 'environmental context and resources', identified in 96% of studies. Barriers within this domain included insufficient time, limited access to and quality of resources, and limited organisational supports. 'Beliefs about consequences' was the second most common TDF domain, reported in 67% of studies, particularly studies of care related to alcohol use, nutrition/ physical activity/ gestational weight gain and those involving midwives, multidisciplinary practitioners and general practitioners. 'Optimism' was the second most common TDF domain for studies of smoking-related care and involving obstetricians, gynaecologists, and other mixed medical professions. Conclusions: It is critical that determinants related to environmental context and resources including time, resources and organisational supports are considered in the development of strategies to support the implementation of recommended antenatal care related to SNAP-W risks. Strategies addressing clinician beliefs about consequences and optimism may also be needed to support the implementation of care related to specific health behaviours and by specific antenatal care provider groups. Registration: The review protocol was prospectively registered with Prospero: CRD42022353084; 22 October 2022. [ABSTRACT FROM AUTHOR]

Background: Urinary tract infections are common affections, especially for women. Difficult access to a general practitioner to obtain a prescription has led France to offer dispensing under protocol by community pharmacists. The primary objective of this study is to evaluate the effectiveness of a pharmacist care protocol provided to manage women with urinary tract infection symptoms. This objective will be assessed using the Acute Cystitis Symptom Score. Methods: PharmaCyst' is an open-label, multicenter, controlled, cluster-randomized study conducted in the Loire region, France. Women aged between 18 and 65 years presenting to a pharmacy complaining of at least one symptom of an uncomplicated urinary tract infection present over the last 3 days (including burning pain during micturition, dysuria, pollakiuria, urgent urination) will be considered for inclusion. All patients will be contacted on day 3, 10, and month 3. A total of 480 patients need to be recruited for the 24 clusters participating in the research. The quantitative data will be described using means and standard deviations and compared using Student's t-test. The qualitative data will be described using numbers and percentages and compared using chi2 test (or Fisher's exact test if necessary). The primary and secondary outcomes analyses will consider the intention-to-treat population. Discussion: PharmaCyst' is the first clinical trial conducted in France only by community pharmacists. Its results could lead to an extension of the protocol. Trial registration: The protocol has been approved by the French ethics committee on 2022/12/02 and is registered under the number 49RC22_0240 on ClinicalTrials.gov. [ABSTRACT FROM AUTHOR]

Background: Opioid-related harms and opioid use disorder (OUD) are health priorities requiring urgent policy responses. There have been many calls for improved OUD care in primary care, as well as increasing involvement of primary care providers in countries like Canada and Australia, which have been experiencing high rates of opioid-related harms. Methods: Using Starfield's 4Cs conceptualization of primary care functions, we examined how and why primary care systems may be suited towards, or pose challenges to providing OUD care, and identified health system opportunities to address these challenges. We conducted 14 semi-structured interviews with 16 key informants with experience in opioid use policy in Canada and Australia. Results: Primary care was identified to be an ideal setting for OUD care delivery due to its potential as the first point of contact in the health system; the opportunity to offer other health services to people with OUD; and the ability to coordinate care with other health providers (e.g. specialists, social workers) and thus also provide care continuity. However, challenges include a lack of resources and support for chronic disease management more broadly in primary care, and the prevailing model of OUD treatment, where addictions care is not seen as part of comprehensive primary care. Additionally, the highly regulated OUD policy landscape is also a barrier, manifesting as a 'regulatory cascade' in which restrictive oversight of OUD treatment passes from regulators to health providers to patients, normalizing the overly restrictive nature and inaccessibility of OUD care. Conclusions: While primary care is an essential arena for providing OUD care, existing sociocultural, political, health professional, and health system factors have led to the current model of care that limits primary care involvement. Addressing this may involve structurally embedding OUD care into primary care and strengthening primary care in general. [ABSTRACT FROM AUTHOR]

Background: Use of antibiotics is the main driver of antimicrobial resistance which is considered one of the biggest threats to human health. In Denmark, most antibiotics are prescribed in general practice. Acute lower respiratory tract infections, including community-acquired pneumonia (CAP), are among the most frequent indications for antibiotic prescribing. Phenoxymethylpenicillin is established as first-line treatment in general practice in Denmark. However, the treatment duration with phenoxymethylpenicillin is mostly based on traditions. Both 5 and 7 days of treatment is recommended in Danish guidelines, and when asking the general practitioners about what treatment duration, they prescribe the variation is even bigger. Several hospital-based studies have proven short course (≤ 6 days) antibiotic treatment non-inferior to long course (≥ 7 days) treatment of CAP. No evidence exists on the optimal treatment duration for CAP in non-hospitalised patients. This randomised controlled trial aim to investigate the optimal treatment duration with phenoxymethylpenicillin for CAP in adults diagnosed in general practice in Denmark. Methods: This is an open-label, pragmatic, randomised controlled, five-arm DURATIONS trial. Participants will be recruited from at least 24 general practices in Denmark. Eligible participants are adults, with no pre-existing lung disease, presenting with symptoms of CAP, and in whom the general practitioner finds it relevant to treat with antibiotics. The study will compare treatment with phenoxymethylpenicillin 1.2 MIE q.i.d. in 3, 4, 5, 6, and 7 days. Discussion: This study will provide evidence for the optimal antibiotic treatment duration of CAP in general practice and inform future guidelines on CAP in all countries using phenoxymethylpenicillin for the treatment of acute respiratory tract infections in adults. The results of this study might also be used to guide treatment recommendations in other countries using phenoxymethylpenicillin. Moreover, a (potential) reduction in antibiotic use might lower the development of antimicrobial resistance, increase patient treatment adherence, reduce risks of adverse events, and lower the economical exp Trial registration: ClinicalTrials.gov: NCT06295120. Registered 28 February 2024. The Scientific Ethics Committee for the North Denmark Region: N-20230039. [ABSTRACT FROM AUTHOR]

Background: The objective of the study was to identify the psychosocial and contextual markers considered by physicians to personalize care. Methods: An online questionnaire with one open-ended question, asking physicians to describe clinical situations in which they personalized care, was used. Physicians were recruited from March 31, 2023, to August 10, 2023, from three hospitals, five university departments of general practice and six physician organizations in France. Recruitment was conducted through email invitations, with participants encouraged to invite their colleagues via a snowball sampling method. The participants were a diverse sample of French general practitioners and other medical specialists who see patients in consultations or in hospital wards. We extracted the psychosocial and contextual markers considered by physicians to personalize care in each clinical situation. The analysis involved both manual and AI-assisted content analysis using GPT3.5-Turbo (OpenAI). Mathematical models to assess data saturation were used to ensure that a comprehensive list of markers was identified. Results: In total, 1340 people connected to the survey platform and 1004 (75.0%) physicians were eligible for the study (median age 39 years old, IQR 34 to 50; 60.5% women; 67.0% working in outpatient settings), among whom 290 answered the open-ended question. The participants reported 317 clinical situations during which they personalized care. Personalization was based on the consideration of 40 markers: 27 were related to patients' psychosocial characteristics (e.g., patient capacity, psychological state, beliefs), and 13 were related to circumstances (e.g., competing activities, support network, living environment). The data saturation models showed that at least 97.0% of the potential markers were identified. Manual and AI-assisted content analysis using GPT3.5-Turbo were concordant for 89.9% of clinical situations. Conclusions: Physicians personalize care to patients' contexts and lives using a broad range of psychosocial and contextual markers. The effect of these markers on treatment engagement and effectiveness needs to be evaluated in clinical studies and integrated as tailoring variables in personalized interventions to build evidence-based personalization. [ABSTRACT FROM AUTHOR]

Background: A novel Complex REsilience-building psychoSocial intervenTion (CREST) targeted at people with dementia, their informal carers, general practitioners and the wider community with the aim of increasing resilience and strengthening the personal attributes or external assets of people with dementia living at home, in the community, was developed. It included three components: cognitive stimulation therapy (CST), physical exercise and dementia education. A non-randomised feasibility study was conducted of the CREST intervention, the aim of which was to inform the design of a future randomised controlled trial. This article presents the findings from the qualitative component of the CREST intervention feasibility study, describing the experience of the people with dementia and their caregivers who participated and the volunteer older adults who supported the intervention. Methods: A descriptive qualitative research approach using semi-structured interviews was undertaken. Key stakeholders (people with dementia (n = 9), their caregivers (n = 9) and the volunteer older adults from the physical exercise component (n = 9)) were interviewed about the intervention and the perceived impact of their participation. Results: The social aspect of the CREST intervention proved to be important for all three groups. Attendance remained high throughout the intervention. The people with dementia spoke positively about their participation in the CST and exercise components of the CREST intervention. The caregivers liked receiving coping strategies focused on how to communicate better with the person they cared for and how to better manage their own self-care and they liked the group element of the programme. The volunteer older adults supported the people with dementia in taking part in the exercise component, motivating them to do the exercises and helping with social interaction within the group. The volunteers gained exposure to the illness and as a result understood more about dementia and felt better equipped to communicate and deal with people with dementia. Conclusion: Participation in the CREST intervention produced a positive impact on all three groups. The social element of the intervention was noted by everybody and was regarded as being beneficial. Qualitative insights emphasised the value of embedding qualitative research within feasibility studies to inform future intervention design. Further research should focus on conducting a full-scale randomised controlled trial to evaluate CREST's effectiveness and explore its application to individuals with more advanced dementia. Trial registration: ISRCTN25294519. [ABSTRACT FROM AUTHOR]

Background: The development of clinical guidelines aimed at GPs is a key strategy to improving the management of chronic kidney disease (CKD). In 2019, the first CKD guideline aimed specifically at GPs practicing in Germany was published by the German College of General Practitioners and Family Physicians (DEGAM.) Aims: The aim of this study is to identify the barriers and enablers for the implementation of this guideline. The results of this project, together with quantitative evaluation against quality indicators for CKD in primary care will inform an update to the guideline. Methods: We performed 17 semi-structured interviews with GPs practicing in Berlin and Brandenburg. Transcripts were analysed using qualitative content analysis as described by Mayring. Results: We found that the perception of low clinical priority of CKD compared to other chronic diseases, opportunity cost of using guidelines, as well as poor patient understanding were significant barriers. GPs expressed that improved graphic design or integration of guideline recommendations in clinical decision support systems were enabling factors. Clinical problems concerning CKD were mostly solved by recourse to informal communication with specialists. GPs reported that they rarely consulted CKD guidelines as an aide to clinical decision making. Conclusion: The most significant barrier to use was that guidelines were not used as step-by-step decision aide in consultations with patients. Our analysis suggests that informal contact between primary and secondary care is significant conduit for evidence-based information on CKD in German primary care. Implementation projects should support the development of these relationships. [ABSTRACT FROM AUTHOR]

Background: Dizziness and vertigo are common referrals to Ear Nose Throat (ENT) outpatient services however these services have long waitlists for assessment. Primary contact physiotherapy-led vestibular clinics are recognized as improving access to care. This pilot study investigated agreement between physiotherapists and an ENT medical practitioner for diagnostic and management decisions in patients attending a primary contact physiotherapy-led vestibular clinic. Methods: Prospective blinded inter-rater agreement study undertaken in an ENT primary contact physiotherapy-led vestibular clinic. Participants were adults referred to ENT from general practitioners, triaged (Category 2 or 3) to the primary contact physiotherapy-led vestibular clinic with clinical symptoms consistent with vestibular disorder. Primary outcome measures included agreement of diagnoses and management decisions made by an ENT medical practitioner and Physiotherapist based on a vestibular physiotherapy assessment. Adverse events were reviewed 11 months post data collection. Gwet's first order agreement co-efficient (AC1) calculated inter-rater reliability between physiotherapy and ENT. Results: Fifty-one participants were recruited consecutively from the primary contact physiotherapy-led vestibular clinic. Physiotherapy and ENT had a substantial agreement (AC1 0.613) on diagnosis. AC1 between physiotherapy and ENT for recommending Magnetic resonance imaging (0.810) and computerized tomography (0.935) both indicated near perfect agreement. There was moderate to near-perfect agreement regarding management recommendations between physiotherapy and ENT. Substantial agreement (AC1 0.720) was found for recommendations for ENT input, near perfect agreement (AC1 0.933) for neurology input and moderate agreement (AC1 0.574) for physiotherapy input. There were no adverse events from physiotherapist's management decision, based on final recommendations undertaken 11-months post data collection. Conclusions: Physiotherapists and ENT medical practitioner made comparable diagnostic and management decisions, based on physiotherapy and audiology hearing assessment, for adults with signs of vestibular dysfunction, within an ENT primary contact physiotherapy-led vestibular clinic. This study provides support for this type of Physiotherapy-led service in managing patients referred to an ENT service with vestibular dysfunction. Key points: 1. This is the first study investigating interprofessional agreement between physiotherapists and an ENT medical practitioner in the diagnosis and management of patients within an ENT primary contact physiotherapy-led vestibular clinic (recommendations were based on a vestibular physiotherapy assessment as participants were not directly assessed by ENT). 2. Physiotherapists and ENT agreement on diagnosis was substantial. 3. Agreement between physiotherapy and ENT on requesting MRI brain and CT head were near perfect; and agreement between physiotherapy and ENT for onward management to ENT, neurology or physiotherapy was moderate to near perfect. 4. There were no adverse events from physiotherapy's management decision, based on the final recommendations. 5. This paper provides support for the competency of physiotherapists in managing patients referred to ENT with vestibular dysfunction and the safety of ENT primary contact physiotherapy-led vestibular clinics, albeit the presence of bias given the recommendations were based on a vestibular physiotherapy assessment only. [ABSTRACT FROM AUTHOR]

Background: Despite the proven positive effects of clinical decision support systems (CDSSs) on general practitioners' (GPs') performance and patient management, their adoption remains slow. Several factors have been proposed to explain GPs' reluctance to adopt these tools. This study hypothesizes that the influence of CDSSs on patient-physician interactions could be a determining factor. To explore this hypothesis, we utilized the FeverTravelApp, designed to assist GPs in managing patients presenting with fever after returning from the tropics. A case–control study was conducted, observing and analyzing fourteen consultations between seven physicians and three simulated patients. Each physician conducted consultations both with and without the FeverTravelApp. The consultations were video-recorded and analyzed using a custom analysis grid based on three existing tools. Simulated patients completed the Communication Assessment Tool (CAT) after each consultation, and each physician participated in a semistructured interview following the use of the app. Results: The use of the FeverTravelApp influenced multiple aspects of the consultation, particularly communication. Both patient and GP speaking times decreased, while active silence (no one talking while the GP actively performed a task) increased. GPs focused more on the app, which reduced direct patient interaction. However, this influence seemed to bother GPs more than simulated patients, who rated their GPs equally whether the app was used or not. This could be because patients felt better understood when GPs asked fewer but more specific questions related to travel medicine, thus effectively addressing their concerns. Conclusions: This study supports the hypothesis that CDSSs influence consultation dynamics, which may contribute to their slow adoption. It is essential to involve clinicians early in the development of CDSSs to adapt them to clinical workflows and ensure system interoperability. Additionally, tools that allow clinicians to follow the entire clinical reasoning process, such as decision trees, are needed. Further research is necessary to confirm these findings in real patient settings and to develop CDSSs that meet both patients' and GPs' expectations. [ABSTRACT FROM AUTHOR]

Background: When doctors seek medical care, there is evidence that the treating doctor can struggle to provide optimal treatment. Guidelines state that doctor-patients should be treated like any other patient, but this is challenging for the treating doctor. This study set out to explore both the positive experiences general practitioners (GPs) have when caring for doctor-patients, and the challenges they confront. It sought to identify whether GPs believe they treat doctor-patients differently to other patients and if so, in what ways, for what reasons, and how this impacts their provision of care. The study also aimed to develop a model that makes sense of GPs' experiences when caring for a patient who is also a medical doctor. Method: Qualitative in-depth interviews with 26 GPs were carried out, with analysis of de-identified transcripts using pragmatic grounded theory. Evolving understandings were used to develop a model to make sense of GPs' experiences caring for their doctor-patients. Results: The core aspects of GPs' experiences of treating fellow doctors centred around concepts of respect and collegiality. These play a central role in mediating how a treating doctor experiences a consultation with a doctor-patient, influencing the quality of care provided. GPs shared that the use of medical language (and assumptions about the doctor-patient's knowledge/behaviours), testing, the exploration of sensitive issues, and the degree of shared decision-making were areas where their treatment might vary when treating a doctor-patient. Treating doctors often experience anxiety about errors and the likely scrutiny from the medical, and wider community. The decision to treat the doctor-patient differently was driven by a desire to maintain a sense of collegiality, to not offend, to meet their doctor-patient's expectations, and to appear competent. Conclusion: The professional socialisation of doctors, with its emphasis on collegiality and respect, plays a significant role in the dynamics of the therapeutic relationship when a doctor treats a doctor-patient. Current guidelines make little reference to these dynamics with the over-simplified 'keep it normal' recommendations. Treating doctors need evidence-informed training to navigate these challenges and ensure they can effectively deliver quality care to their doctor-patients. [ABSTRACT FROM AUTHOR]

Background: Effective transitions of patients from Secondary Care Services (SCSs) to primary care are necessary for optimization of resources and care. Factors that enable or restrict smooth transitions of individuals with Serious Mental Illness (SMI) to primary care from SCSs have not been comprehensively synthesized. Methods: A scoping review was conducted to answer the questions (1) "What are the barriers and facilitators to discharge from SCSs to primary care for adults with SMI?" and (2) "What programs have been developed to support these transitions?". Results: Barriers and facilitators of discharge included patient-, primary care capacity-, and transition Process/Support-related factors. Patient-related barriers and facilitators were most frequently reported. 11 discharge programs were reported across the evidence sources. The most frequently reported program components were the provision of additional mental health supports for the transition and development of care plans with relapse signatures and intervention plans. Conclusions: Established discharge programs should be comprehensively evaluated to determine their relative benefits. Furthermore, research should be expanded to evaluate barriers and facilitators to discharge and discharge programs in different national contexts and models of care. Trial Registration: The protocol for this scoping review is registered with the Open Science Framework (https://doi.org/10.17605/OSF.IO/NBTMZ). [ABSTRACT FROM AUTHOR]

Background: Polypharmacy and inappropriate drug use are associated with adverse health outcomes in older people. Collaborative interventions between geriatricians and general practitioners have demonstrated effectiveness in improving clinical outcomes for complex medication regimens in home-dwelling patients. Since 2012, Norwegian municipalities have established municipal in-patient acute care (MipAC) units, designed to contribute towards reducing the number of hospital admissions. These units predominantly serve older people who typically benefit from multidisciplinary approaches. The primary objective of this study is to evaluate the effect of cooperative medication reviews conducted by MipAC physicians, supervised by geriatricians, and in collaboration with general practitioners, on health-related quality of life and clinical outcomes in MipAC patients ≥ 70 years with polypharmacy. Additionally, the study aims to assess the carbon footprint of the intervention. Methods: This is a randomized, single-blind, controlled superiority trial with 16 weeks follow-up. Participants will be randomly assigned to either the control group, receiving usual care at the MipAC unit, or to the intervention group which in addition receive clinical medication reviews that go beyond what is considered usual care. The medication reviews will evaluate medication appropriateness using a structured but individualized framework, and the physicians will receive supervision from geriatricians. Following the clinical medication reviews, the MipAC physicians will arrange telephone meetings with the participants' general practitioners to combine their assessments in a joint medication review. The primary outcome is health-related quality of life as measured by the 15D instrument. Secondary outcomes include physical and cognitive functioning, oral health, falls, admissions to healthcare facilities, and mortality. Discussion: This study aims to identify potential clinical benefits of collaborative, clinical medication reviews within community-level MipAC units for older patients with polypharmacy. The results may offer valuable insights into optimizing patient care in comparable municipal healthcare settings. Trial registration: The study was registered prospectively on ClinicalTrials.gov 30.08.2023 with identifier NCT06020391. [ABSTRACT FROM AUTHOR]

Background: Multicomponent interventions based on a comprehensive geriatric assessment (CGA) could promote active aging and improve health status in older people with Noncommunicable Chronic Diseases (NCDs), but conflicting evidences are available. Aim: To evaluate the efficacy of a CGA-based multicomponent personalized preventive program (PPP) in reducing unplanned hospitalization rates during 12-month follow-up in community-dwelling older people with NCDs. Materials and methods: In this randomized clinical trial (RCT), 1216 older adults recruited by 33 general practitioners (GPs) will be randomly allocated to intervention group (IG) or usual care control group (CG). The IG will receive a multicomponent PPP developed on the findings of the CGA-based Multidimensional Prognostic Index short-form (Brief-MPI), including structured interventions to improve functional, physical, cognitive, and nutritional status, to monitor NCDs and vaccinations, and to prevent social isolation. Participants in the CG will receive usual care. Brief-MPI, resilience, and health-related quality of life will be assessed after 6 and 12 months. Moreover, saliva samples will be collected at baseline in IG to measure biomarkers of oxidative stress, inflammatory cytokines, and oral microbiome. Expected results: The CGA-based PPP might reduce unplanned hospitalization rates and potentially institutionalization rates, emergency department (ED) and unplanned GP visits, and mortality. Further outcomes explored in the IG will be the adherence to PPP, resilience, health-related quality of life, and multidimensional frailty as assessed by the Brief-MPI. Conclusions: Results will suggest whether the CGA-based multicomponent PPP is able to improve specific outcomes in a primary care setting. Trial registration: ClinicalTrials.gov; identifier: NCT06224556; Registered January 25, 2024. [ABSTRACT FROM AUTHOR]

Background: Exposure to domestic and family violence is a pervasive form of complex trauma and a major global public health problem. At the frontline of the health system, primary healthcare practitioners are uniquely placed to support individuals with experiences of trauma, yet their views on trauma-informed primary care are not well understood. This systematic review of qualitative literature sought to explore primary healthcare practitioners' perspectives on trauma-informed primary care. Methods: Eight databases were searched up to July 2023. Studies were included if they consisted of empirical qualitative data, were conducted in general practice or equivalent generalist primary healthcare settings, and included the perspectives of primary healthcare practitioners where they could be distinguished from other participants in the analysis. Thematic synthesis was used for analysis. Results: 13 papers met inclusion criteria, representing primary care settings from the United States, Canada, Australia, and Norway. Three key themes were developed: Changing the paradigm, Building trust, and Navigating the emotional load. Findings shed light on how primary healthcare practitioners perceive and strive to practise trauma-informed primary healthcare and the challenges of navigating complex, trauma-related work in the primary care environment. Conclusions: This review supports the need for recognition of the value of primary care in supporting patients with histories of trauma and violence, the development of interventions to mitigate the emotional load worn by primary healthcare practitioners, and further work to develop a deep and consistent understanding of what trauma-informed primary care encompasses. [ABSTRACT FROM AUTHOR]

Background: Although the number of point-of-care ultrasound devices available in Hungarian primary care practices are increasing due to government funding, their use in day-to-day patient care is limited and unregulated. Our study aimed to evaluate the attitudes and needs of general practitioners (GPs) and patients in Hungary regarding the introduction of bedside ultrasonography in primary care practices. Methods: As a part of a cross-sectional study, an anonymous, self-administered questionnaire was distributed to GPs and patients on a social media platform. Data collection was carried out from August 2023 to October 2023. Chi-square test was used to determine the associations between categorical variables. Results: The survey was completed by 415 GPs (mean age 53.8 ± 11.1 years, 54.9% female, mean 19.5 ± 11.9 years of practice) and 693 patients (mean age 45.5 ± 12.3 years, 95.2% female). There was a statistically significant increase in interest in PoCUS among young and middle-aged GPs (age 28–59; p = 0.02). In addition, this population of GPs was also more likely to undertake training in PoCUS than their older colleagues (p < 0.0001). An inverse relationship was found between the duration of practice and training willingness (p = 0.0011). Even with the government's financial support, only 8.2% of GPs currently use PoCUS in a daily basis, and 59.5% of GPs are unfamiliar with the indications and the ways of using it. Patients would even pay to have the examination done in a primary care setting, even though only 45.9% of patients would pay a GP who is not certified in PoCUS, but the willingness to pay increased to 99.4% for those with formal training (p = 0.024). Conclusion: Our findings indicate a significant interest in adapting PoCUS in primary care from both GPs and patients. Based on the fact that a significant proportion of Hungarian GPs are unaware of PoCUS and its indications, it is particularly important to develop educational frameworks, and practical guidelines for the effective incorporation of PoCUS in Hungary. [ABSTRACT FROM AUTHOR]

Background: Women with breast cancer face many barriers to return to work (RTW) after their cancer. The main objective of the FASTRACS-RCT is to evaluate the impact of the FASTRACS (Facilitate and Sustain Return to Work after Breast Cancer) intervention on the sustainable RTW of breast cancer patients, 12 months after the end of active treatment. Methods: FASTRACS-RCT is a prospective, national, multicentre, randomized, controlled and open-label study. A total of 420 patients with early breast cancer scheduled for surgery and (neo)adjuvant chemotherapy, will be randomly assigned (1:1 ratio) to: (i) the intervention arm comprising four steps over 6 months : Handing over the intervention tools; transitional medical consultation with the general practitioner (GP); pre-RTW visit with the company's occupational physician (OP); catch-up visit with a hospital-based RTW expert (if sick leave > 10 months) (ii) the control arm to receive usual care. The design of the FASTRACS intervention was informed by intervention mapping for complex interventions in health promotion planning, and involved patients and representatives of relevant stakeholders. Specific tools were developed to bridge the gap between the hospital, the GP, the OP and the workplace: a toolkit for breast cancer patients comprising a theory-based guide; specific checklists for the GP and the OP, respectively; and a theory-based guide for workplace actors (employer, manager, colleagues). The primary endpoint will associate sustainable RTW (full-time or part-time work at 50% or more of working time, for at least 28 consecutive days) and days off work. It will be assessed at 4, 8 and 12 months after the end of active oncological treatment. Secondary endpoints will include quality of life, anxiety, depression, RTW self-efficacy, physical activity, social support, job accommodations, work productivity, job status, and the usefulness and acceptability of the intervention's tools. Discussion: FASTRACS-RCT will be supplemented by a realist evaluation approach aimed at understanding the influence of context in activating the intervention's mechanisms and effects. If the expected impact of the intervention is confirmed, the intervention will be adapted and scaled-up for other cancers and chronic diseases to better integrate healthcare and work disability prevention. Trial registration: NCT04846972 ; April 15, 2021. [ABSTRACT FROM AUTHOR]

Background: Telemedicine allows delivery of healthcare to occur between parties that are not in the same location. As telemedicine users are not co-present, effective communication methods are crucial to the delivery and reception of information. The aim of this study was to explore perspectives of general practitioners (GPs) and patients on the interactional components of telemedicine consultations. Methods: Semi-structured qualitative interviews were held with telemedicine users; 15 GPs and nine patients self-selected from a larger telemedicine study. Participants were asked about their preparation for telemedicine consultations, conducting telemedicine consultations and post-consultation activities. Deidentified transcripts from the interviews were analysed thematically. Results: GPs and patients discussed factors they used to decide whether a consultation would be best conducted by telemedicine or in-person; the condition to be discussed, the existing doctor-patient relationship and whether physical examination was required. Participants also described how they prepared for their telemedicine consultations, gathering relevant documents, and reading previous notes. Participants described strategies they employed to optimise the telemedicine interaction; improving conversational flow and building rapport, as well as difficulties they experienced when trying to provide and receive care via telemedicine. Conclusions: Patient factors including health literacy and familiarity with technology affect the transfer of information shared during telemedicine consultations and consideration of these factors when choosing patients for telemedicine is required. Many GPs and patients have innate communication skills to effectively deliver and receive care through telemedicine. However, they may not be aware of these subconscious techniques to use to optimise telemedicine consultations. Communication training could be delivered to increase conversational flow, build rapport, and establish safety netting. [ABSTRACT FROM AUTHOR]

Background: The effectiveness of the NSW Health "Get Healthy Information and Coaching Service®"(Get Healthy) to facilitate weight loss on a population scale has been documented, but this was based on self-reported measures. Our study aims to test the effectiveness of the Get Healthy Service on objectively measured weight, BMI, waist circumference, and changes in other health behaviours, including nutrition, physical activity and alcohol intake. Methods: Men and women aged 40–70 years (n = 154) with pre-diabetes (5.7% < HbA1c < 6.5%) were referred from GP Practices to the Get Healthy Service, NSW Health. A subset (n = 98) participated in the "Zinc In Preventing the Progression of pre-Diabetes" (ZIPPeD) trial (ACTRN12618001120268). Results: The self-reported outcomes showed a statistically significant improvement from baseline to 12 months in weight (mean 2.7 kg loss, p < 0.001), BMI (mean 1 unit reduction, p < 0.001), and waist circumference (mean 4.3 cm reduction, p < 0.001). However, in the objectively measured outcomes from ZIPPeD, the differences were more modest, with point estimates of 0.8 kg mean weight loss (p = 0.1), 0.4 unit reduction in BMI (p = 0.03), and 1.8 cm reduction in waist circumference (p = 0.04). Bland-Altman plots indicated that discrepancies were due to a small number of participants who dramatically underestimated their weight or BMI. There were minimal changes in nutrition, physical activity, and alcohol. Conclusions: The potential benefits of Get Healthy should be interpreted with caution as we have shown significant differences between self-reported and objectively measured values. More valid and objective evidence is needed to determine the program's effectiveness and cost-effectiveness. [ABSTRACT FROM AUTHOR]

Health care challenges in remote rural municipalities (RRMs) emphasize the importance of primary health care (PHC) and require an expanded scope of practice. Doctors are key actors in this context. The aim of this study was to explore the level of integration of doctors in RRMs and working practices. We conducted a qualitative study involving semi-structured interviews with 46 PHC doctors working in 27 RRMs in Brazil. Content analysis was performed, resulting in the identification of categories of analysis grouped under three core dimensions: doctor training and experience; comprehensive care and timely access; and the community-based approach. Doctors working in RRMs were mainly recent graduates with limited experience who had undertaken their degree outside Brazil, and care was focused on the individual. The findings also revealed weak sociocultural adaptation and a harsh working environment and issues related to social status that reinforced prejudice against rurality and poverty. Practice was limited in scope and care tended to be oriented towards acute problems, disease-centered and focused on the biomedical model of medicine. Barriers to the delivery of comprehensive care include both structural constraints, such as poor facilities and centralization of services in administrative centers, and the lack of professional competencies necessary for PHC in these areas. The findings point to the need to promote an expanded scope of practice in PHC delivery in RRMs, with major public investment in the promotion of training and strengthening career pathways in these areas. [ABSTRACT FROM AUTHOR]

Background: This study aimed to explore the influence of patient-, general practitioners (GP)-, and GP practice-level predictor variables on patient-experienced accessibility to GPs and GP practices. Additionally, we aimed to enhance our understanding of patient-experienced accessibility by analysing the free-text comments from patients who reported lowest accessibility scores to GPs and GP practices. Methods: We performed a secondary analysis of data from a 2021-2022 national Norwegian survey on patient experiences with their GP and GP practice. We identified seven accessibility-related items including experience and acceptance of regular waiting time and for urgent appointments, time spent with the GP, waiting time in the wating-room, and getting in touch with the GP practice by telephone. A composite accessibility score was computed. Predictor variables consisted of patient's self-reported characteristics, as well as background data about the GP and GP practice from National GP registry. The analysis included multiple linear regression of the composite accessibility score and seven accessibility items. Finally, a qualitative analysis was conducted of free-text survey comments among patients that had a score of 0 (unfavourable) on all the seven accessibility items. Results: The key factor for patient-experienced accessibility to general practice was seeing their own GP, showing a statistically significant positive correlation (p<0.001) across all seven accessibility items and the composite accessibility score in regression analyses. Other associations with positive experience included better self-reported health, and at the GP-level, a specialization in general medicine. Conversely, a negative experience was associated with longer time since the last GP consultation, female patients, and a higher number of GPs at the practice. Qualitative data confirmed accessibility challenges, detailing quantitative scores and highlighted that low accessibility scores were related to difficulties in seeing one's own GP. Conclusions: This study highlights the importance of continuity between patient and their GP in improving patients' experiences of accessibility to general practice. Several GP and GP practice-level factors were related to patient-reported accessibility. These results can be used to inform initiatives aimed at improving accessibility to general practice. [ABSTRACT FROM AUTHOR]

Background: Digital therapeutic Sleepio has proven effective in improving sleep quality and decreasing symptoms of anxiety. The National Institute for Health and Care Excellence (NICE) guidance recommends Sleepio as an alternative treatment to usual sleep hygiene education and hypnotic medications. General practitioners (GPs) play a critical role in the adoption of digital therapeutics in patient care. Previous interventions did not adopt theoretical frameworks to systematically understand GPs behaviour toward referring patients to digital therapeutics. Objectives: This study aimed to report the systematic and comprehensive development of an intervention to encourage GPs to refer insomnia patients to Sleepio, using the Behaviour Change Wheel (BCW). Methods: The eight steps outlined in the BCW were followed to develop an intervention. The Capability Opportunity Motivation-Behaviour Self-Evaluation Questionnaire (COM-B-Qv1) was adopted to understand GPs perceived facilitators and barriers to refer insomnia patients to Sleepio. The Behaviour Change Technique Taxonomy Version 1 (BCTv1) was thereafter used to identify possible strategies that could be used to facilitate changes in GPs' behaviour in relation to Sleepio. Results: The BCW design process resulted in the identification of five intervention functions, three policy categories and five behaviour change techniques (BCTs) as potential active components for an intervention. The intervention includes providing GPs with an orientation about using Sleepio to improve their knowledge and confidence, sending visual reminders to GPs to recommend Sleepio to their patients, providing ongoing technical support. Conclusion: The BCW can be successfully applied through a systematic process to understand the drivers of GPs' behaviour and to develop an intervention that can encourage them to refer insomnia patients to Sleepio. [ABSTRACT FROM AUTHOR]

Background: Seasonal influenza vaccination coverage in Italian older adults is insufficient and well below the minimum target of 75%. In Italy, most influenza vaccine doses are administered by general practitioners (GPs), whose number has been declining. In parallel, the number of patients per GP and GP workload increased dramatically, which theoretically may impair vaccination counselling. In this ecological study, we aimed to assess whether influenza vaccination coverage in older adults is associated with the density of GPs having high number of patients. Methods: The study outcome was the influenza vaccination coverage rate in adults aged ≥ 65 years and registered in 20 Italian regions over the last 23 years. The independent variable of interest was the proportion of GPs with more than 1,500 adult patients, which is an imposed normative ceiling. This latter variable was considered as a proxy of GP overload. By adopting a panel regression approach, different specifications of fixed- and random-effects models were run to assess the association of interest, when adjusted for several social structural, economic and healthcare-related variables. Results: Over the last two decades, most regions showed a negative association between influenza vaccination coverage rates and the density of GPs with a high number of patients. This latter negative association was confirmed (P < 0.05) in different panel model specifications. In particular, in the fully adjusted two-way fixed-effects model, each 10% increase in the number of GPs with more than 1,500 patients was associated with a 1.7% decrease in influenza vaccination coverage. However, this association was present only in region-years where at least 18% of GPs were deemed overloaded. Conclusions: In the upcoming years, the number of Italian GPs is projected to decline further. At the same time, the aging Italian population will determine an even greater workload for GPs. This study demonstrated that increased GP workload may partially explain the spatiotemporal variation in influenza vaccination uptake in the Italian elderly. With the imperative of increasing or at least maintaining influenza vaccination coverage rates, several short- and mid-term initiatives should be implemented in order to optimize GP workload during seasonal immunization campaigns. [ABSTRACT FROM AUTHOR]

Background: Having knowledge of the dental procedures that necessitate endocarditis prophylaxis is of high importance. Therefore, the aim of the present study was to determine the knowledge level and attitudes of general medical and dental practitioners, dental specialists, and cardiologists in Tehran and Hamadan about endocarditis. Methods: This cross-sectional study was carried out on 420 general medical and dental practitioners, dental specialists, and cardiologists in Tehran and Hamadan provinces in 2015. The questionnaire used in this research consisted of three parts as follows: part one: information on cardiac diseases; part two: dental procedures requiring endocarditis prophylaxis; part three: antibiotic diet in endocarditis prophylaxis. Independent t-test, one-way ANOVA, and chi-square tests were conducted to analyze the data. All the analyses were performed in SPSS version 16. Results: The results showed that 86.7 had a relatively favorable and 10.5% of subjects had a favorable level of knowledge about endocarditis. Also, 58.6% of subjects had a poor attitude toward endocarditis prophylaxis. There was a significant relationship between knowledge and attitude, age, gender, and work experience (P < 0.001). There was a significant relationship between knowledge and attitude, and job groups; dental specialists had a more favorable knowledge and positive attitude than others (P < 0.001). Conclusion: We recommended developing more practical training programs in dental schools on cardiac diseases, and dental procedures requiring endocarditis prophylaxis and antibiotic diets. [ABSTRACT FROM AUTHOR]

Background: A longer duration of untreated psychosis (DUP) is associated with poorer treatment outcomes. Screening for psychosis spectrum disorders in the primary care setting could help support the earlier detection and treatment of individuals in need. However, the acceptability of screening for psychosis in this setting as part of routine care is currently unknown. Methods: We conducted a qualitative interview study with providers and service users who participated in an early psychosis screening program conducted in an integrated behavioral health primary care (IBH-PC) setting. Interviews were recruited from one of eight WellSpace Federally Qualified Health Center IBH-PC clinics in the Sacramento, CA area. Transcripts of the recorded interviews were analyzed using thematic analysis. Results: In total, 12 providers and eight service users participated in the interviews. Most service user and provider participants were supportive of psychosis screening in an IBH-PC setting, but not as part of the general practitioner consultation due to the brief, non-behavioral health nature of many of the appointments, and the expected low prevalence of psychosis in this population. The support of leadership, adequate training and support, staff turnover, and organizational changes were all seen to impact the successful implementation of the program. Different barriers and facilitators were considered important at each stage of the process from introducing the screening procedures to service users; to determining when, where, and how to screen; and how to effectively manage the referral and post-referral stages. Conclusions: Despite the additional challenges of screening in an IBH-PC setting relative to secondary mental health services, the process was considered acceptable and feasible to providers and service users. Services that plan to conduct psychosis screening in their clinics need to consider the challenges and their potential solutions to implementation at each stage of the screening process. [ABSTRACT FROM AUTHOR]

Background: Multiple myeloma often presents with vague and non-specific symptoms. Many patients are diagnosed in unplanned rather than elective (planned) diagnostic pathways. This study investigates the diagnosis of multiple myeloma in unplanned pathways and the association with patient characteristics, disease profile, and survival. Methods: We conducted a nationwide register-based study, including all patients diagnosed with multiple myeloma in Denmark in 2014–2018. Patients were categorised as diagnosed in an unplanned pathway if registered with an acute admission within 30 days prior to the multiple myeloma diagnosis and no other previously registered pathway to this diagnosis. Unplanned pathways were compared to all other pathways combined. Results: We included 2,213 patients diagnosed with multiple myeloma, hereof 32% diagnosed in an unplanned pathway. Comorbidity, no prior cancer diagnosis, a history of few visits to the general practitioner (GP), multiple myeloma complications at diagnosis, high-risk cytogenetics, and advanced cancer stage were associated with a higher probability of being diagnosed in an unplanned pathway. For example, 24.4% (95% confidence interval (CI): 21.8–27.0) of patients with low comorbidity (Charlson Comorbidity Index (CCI) score 0) were diagnosed in an unplanned pathway as were 50.9% (95% CI: 45.6–56.1) of patients with high comorbidity (CCI score 3+). For patients with dialysis need at the time of diagnosis the probability was 66.0% (95% CI 54.2–77.8) and 30.9% (95% CI: 28.9–32.9) for patients with no dialysis need. Patients diagnosed in an unplanned pathway had inferior survival (hazard ratio 1.44 (95% CI: 1.26–1.64)). However, this association was not seen in analyses restricted to patients surviving for more than three years. Conclusions: High comorbidity level, few usual GP visits, advanced disease status at diagnosis, and complications were associated with diagnosis in an unplanned pathway. Further, patients diagnosed in an unplanned pathway had inferior survival. Promoting earlier diagnosis and preventing unplanned pathways may help improve survival in multiple myeloma. [ABSTRACT FROM AUTHOR]

Background: The aim of this study is to explore the influence of GPs'information, motivation and behavior skills on EM prescribing behavior in urban and suburban districts. Method: A cross-sectional study was conducted from June to November 2022 cross 3 urban districts and 4 suburban districts in Beijing. The structural equation model was used to analyze the factors influencing the essential medicine prescription behavior among general practitioners in urban and suburban districts. Results: A total of 511 valid questionnaires were collected. There was a statistically significant difference in mean scores for personal motivation and behavioral skills between urban GPs and suburban GPs. For urban GPs, the path analysis revealed that the social motivation had a direct effect on the essential medicine prescribing behavior (β = 0.225, p < 0.05). In contrast, for suburban GPs, both social motivation and personal motivation had a direct effect on the essential medicine prescribing behavior, respectively (β = 0.175, p < 0.05; β = 0.193, p < 0.01). Conclusion: Social motivation of urban GPs were positively and significantly associated with essential medicine prescribing behavior. Social motivation and personal motivation of suburban GPs were positively and significantly associated with essential medicine prescribing behavior. Therefore, various corresponding policies and measures should be developed to promote the National Essential Medicines Policy in China. [ABSTRACT FROM AUTHOR]

Background: Primary care is an essential pillar of health systems. Many countries have implemented different policies to improve access to primary care. However, persistent challenges remain. This paper offers a critical analysis of the evolution of primary care coverage in Portugal, focusing on the number of patients without an assigned general practitioner (GP). Methods: We collected and analyzed publicly available data from 2009 to 2023 to decompose primary care coverage in three components: the number of patients enrolled in primary care units (demand-side effect), the number of GPs measured in full-time equivalent (supply-side effect), and the average number of patients on each GP's list (patient-to-GP ratio, capturing a productivity effect). We provide national and local level estimates for these three components. Results: Between 2009 and 2023, there was an overall decline in the number of patients enrolled in primary health care units. Concurrently, there was also a net decrease of GPs measured in full-time equivalent. Additionally, there was a progressive reduction in the average number of patients on each GP's list. The rise in the number of patients without an assigned GP is attributed not only to a reduction in the number of physicians, but also to a decrease in the patient load per doctor. Conclusions: Hiring additional GPs may not suffice to enhance coverage. Achieving higher coverage may imply revisiting patient load per doctor or considering alternative care models. Understanding the challenges related to GP coverage is critical for improving the efficiency of primary care. [ABSTRACT FROM AUTHOR]

Background: In Germany, general practitioners play a pivotal role in palliative care provision. Caring for patients with palliative care needs can be a burden for general practitioners, highlighting the importance of self-care and mental health support. This study aimed to explore the role of palliative care in general practitioners' daily work, the stressors they experience, their coping mechanisms, and the potential benefits of Advance Care Planning in this context. Methods: An exploratory approach was employed, combining a short quantitative survey with qualitative interviews. The analysis was based on a structuring qualitative content analysis, following a deductive-inductive procedure and integrating the Stress-Strain Model and Lazarus' Transactional Model of Stress and Coping. We recruited eleven general practitioners to take part in the study. Results: General practitioners viewed palliative care as integral to their practice but faced challenges such as time constraints and perceived expertise gaps. Societal taboos often hindered conversations on the topic of death. Most general practitioners waited for their patients to initiate the topic. Some general practitioners viewed aspects of palliative care as potentially distressing. They used problem-focused (avoiding negative stressors, structuring their daily schedules) and emotion-focused (discussions with colleagues) coping strategies. Still, general practitioners indicated a desire for specific psychological support options. Advance Care Planning, though relatively unfamiliar, was acknowledged as valuable for end-of-life conversations. Conclusions: Palliative care can be associated with negative psychological stress for general practitioners, often coming from external factors. Despite individual coping strategies in place, it is advisable to explore concepts for professional psychological relief. Trial registration: Not registered. [ABSTRACT FROM AUTHOR]

Introduction: The health system in Sudan faces several challenges, including increasing numbers of patients, shortages of health supplies, and disparities in the distribution of health services. Guidelines implementation improves patients' outcomes and ensures efficient use of the resources in such a resource limited country. The study aimed to assess the implementation of the clinical practice guidelines among family medicine doctors working in the primary health care centers in Khartoum and Gezira states to provide baseline data about the current practice in Sudan. Methods: Descriptive cross-sectional facility-based survey, conducted from April to December 2021, on 373 of the practicing family-medicine doctors. A total of 101 Primary health care centers were surveyed (77 centers in Khartoum state and 24 in Gezira state). The questionnaire was pilot tested on a small group of physicians to improve clarity and reduce response bias. Descriptive statistics were used to summarize the data and analyzed by frequency tables. Chi square and logistic regression tests were used to determine the association between categorized variables. P value < 0.05 was considered statistically significant. Results: Most of the practicing family-medicine doctors (98.4%) reported implementation of the guidelines. Moreover, (68.6%) of them received training programs which were organized and funded by the Sudan Ministry of Health. The local Sudanese guidelines were difficult to access and not regularly updated. Services unavailability and inaccessibility (87.1%), health insurance factors (83.9%), and patient factors (81.2%) were the most frequent barriers to guidelines implementation. Service cost (79.9%), lack of regular training programs (79.9%), absence of local guidelines (77.2%), lack of continuity in the comprehensive care process (63.0%), and lack of time (57.1%) were also reported as barriers to guidelines implementation. Conclusion: Guidelines implementation is limited by unavailability and inaccessibility of the health services and the health insurance limited coverage. Expansion of the health insurance coverage, organization of continuous training programs, encouragement of regular auditing and issuing regulations to ensure the use of updated guidelines, dissemination of the updated national guidelines along with establishing clinical governance in Sudan can be useful tools for policymakers in the optimum allocation of public health resources. [ABSTRACT FROM AUTHOR]

Background: Basic sciences are crucial for clinical medicine, yet studies focusing on their perceived utility among general practitioners (GPs) are sparse. Considering the broad scope of GPs' practice, an in-depth understanding of basic sciences is fundamental for making informed clinical decisions. This study evaluated GP registrars' retention and perceptions of the utility of basic sciences in clinical practice. Methods: Using sequential explanatory mixed methods study design, knowledge retention was assessed by a multiple-choice question (MCQ) examination followed by interviews on the perception of the relevance and utility of basic sciences among GP registrars at James Cook University's (JCU) General Practice Training (GPT) program. Descriptive and inferential statistical analyses were conducted on the MCQ exam data, while thematic analysis was employed for the qualitative interview data. Results: Sixty-one GP registrars participated in the MCQ exam, while 11 of them were involved in the interviews. The highest mean score was obtained in biochemistry (75.1 ± 2.23) while the lowest mean score was in anatomy (56.07 ± 3.16). Key performance predictors included the formative clinical examination scores (β = 0.83, 95% CI: 0.45 to 1.2, p < 0.001) and gender (β = -9.7, 95% CI: -17 to -2.3, p = 0.011). The qualitative data analysis revealed five themes, including the backbone of clinical medicine, varying utility over time and by specialty, clinical synthesis integrates encapsulated knowledge, professional pressures hinder revisitation of knowledge and knowledge renewal enhances updates. Conclusion: Basic sciences were considered relevant in clinical practice. Development of continuing professional development (CPDs) sessions and clinically relevant online resources were measures proposed to enhance the retention of knowledge. Future research could focus on innovative educational strategies for GPs. [ABSTRACT FROM AUTHOR]

Background: The vaccine coverage rate (VCR) for human papillomavirus (HPV) in France is one of the lowest in Europe, well below the target of 80% announced in the French Cancer Plan 2021–2030. The extension of vaccination competencies (prescription and administration) to new health care providers, such as community pharmacists (CPs), was a decisive step by the French Health Authority (HAS) in 2022 to simplify access to vaccination and improve the VCR. This research assessed the economic and organizational impacts (OIs) of the extension of vaccination competencies in France. Methods: A model was developed in Excel® to compare the current HPV vaccination pathway focused on general practitioners (GPs) to a mix of pathways (new and current) that extends pharmacists' competencies (prescription and/or injection). The simulated population corresponded to girls and boys targeted by the French recommendations. The model was run from 2023 to 2030. HAS guidelines were used to identify OIs related to these new pathways. Model inputs were collected from national data sources and an acceptability study. The results focused on three OIs (HPV vaccination ability [defined as the number of adolescents who could be vaccinated in each pathway], the VCR projection, and flows of activity between health care professionals]). The economic impact was evaluated from the National Health Insurance (NHI) perspective in 2022. Results: With a mix of vaccination pathways, including an increasing role of pharmacists, the target of an 80% VCR could be reached in 2030 (versus 2032 with the current pathway) with lower investment than the current situation, resulting in cost savings for the NHI of €212 million. Expanding vaccination competencies will provide pharmacists with additional revenue (an average of €755,000/month for all vaccinating pharmacies) and will free up medical time for GPs (average of 603,000 consultations/year for all GPs). Conclusions: Expanding vaccination competencies to pharmacists has a positive impact on the entire ecosystem. From a public health perspective, the national VCR target can be achieved and better access to care can be provided, freeing up medical time. From an economic perspective, this approach can provide savings for the NHI and additional revenue for pharmacists. [ABSTRACT FROM AUTHOR]

Background: Older patients with type 2 diabetes mellitus (T2D) have an increased risk of hypoglycaemic episodes when using sulphonylureas or insulin. In the Netherlands, guidelines exist for reducing glucose-lowering medication in older patients. However, evidence is lacking that a medication reduction in older patients can be safely pursued. Here, we will examine if promoting the deprescribing of insulin/sulphonylureas with a deprescribing programme (DPP) in general practice affects T2D-complications in older overtreated patients. Methods: We will perform a 1:1 cluster randomised controlled trial in 86 general practices in the Netherlands. The DPP will consist of education sessions with general practitioners and practice nurses about reducing glucose-lowering medication in older patients (≥ 70 years). Topics of the sessions include the necessity of deprescribing, tools to initiate deprescribing and strategies to discuss deprescribing with patients (shared decision making). The DPP further includes a support programme with practice visits. The study will employ a selection tool to identify possibly overtreated older patients from the electronic medical records of the general practitioner. Eligibility for enrolment in the study will be based on HbA1c targets indicated by the Dutch guidelines, which depend on age, diabetes duration, presence of frailty, and life expectancy. The control group will provide usual care. We aim to include 406 patients. The follow-up period will be 2 years. For the primary outcome, the effect of the DPP on T2D-complications will be assessed by counting the cumulative incidence of events related to under- and overtreatment in T2D as registered in the electronic medical records. We shall perform an intention-to-treat analysis and an analysis including only patients for whom deprescribing was initiated. The implementation of the DPP in general practice will be evaluated quantitatively and qualitatively using the Extended Normalisation Process Theory (ENPT) and the Reach, Efficacy – Adoption, Implementation and Maintenance (RE-AIM) model. Other secondary outcomes include quality of life, cognitive functioning, events related to overtreatment or undertreatment, biomarkers of health, amount of blood glucose-lowering medication prescriptions, and cost-effectiveness. Discussion: This study will provide insight into the safety and feasibility of a programme aimed at deprescribing sulphonylureas/insulin in older people with T2D who are treated in general practice. Trial registration: ISRCTN Registry, ISRCTN50008265, registered 09 March, 2023. [ABSTRACT FROM AUTHOR]

Background: France allows deep sedation for pain relief, but not for euthanasia. In anticipation of an increase in home-based palliative care, the role of general practitioners is central to the design of outpatient palliative care services. This study aimed to describe the knowledge, attitudes, and practices of general practitioners in mainland France regarding palliative and end of life care. Methods: This was a national descriptive cross-sectional study within the Sentinelles network. Self-report questionnaires were distributed to general practitioners between November 2020 and November 2021. A descriptive analysis was carried out. Results: Out of the 123 participating general practitioners, 84% had received academic training in palliative care (n = 104). While a significant majority (69%) expressed comfort in pain management, only a quarter (25%) declared that they were competent at indicating deep and continuous sedation for pain relief. Awareness of outpatient palliative care facilities close to their place of practice such as hospitalization at home was over 97% (n = 117/120). Awareness of hospital facilities, including identified palliative care beds on hospital wards and palliative care units, was lower (75% (n = 59/79) and 86% (n = 86/100), respectively). Conclusions: Our results suggest that French general practitioners are reasonably aware of palliative care resources available. However, there is room for improvement, particularly in understanding hospital-based facilities. Furthermore, a quarter of the general practitioners expressed discomfort with deep and continuous sedation for pain relief, highlighting the need for increased training in this specific aspect of palliative and end of life care. [ABSTRACT FROM AUTHOR]

Background: Use of cannabis-based products is becoming more frequent, and it is important that healthcare professionals are informed and confident about them when making evidence-based decisions about their use. This study aimed to gain an international perspective on the attitudes, knowledge, and confidence of healthcare professionals about cannabis-based products. Methods: An online questionnaire regarding these products was completed by 1580 healthcare professionals (neurologists, psychiatrists, general practitioners, pharmacists and nurses) from 16 countries across Asia, Europe, Oceania, South America, and the Middle East. Results: Respondents expressed a high level of interest in cannabis-based products (median score 9 out of 10) and reported that they felt knowledgeable about them (median score 6 out of 7). They reported a high level of confidence when providing patients with information on cannabis-based products, returning median scores of 6 and 5 out of 7 for their legality and regulations, and their benefits and risks, respectively. Despite this, healthcare professionals sought further information on cannabis-based products across areas including legality, neurobiology, and scientific evidence. Finally, 59% (n = 930) of respondents considered robust clinical trial evidence as the most important factor to ensure patient safety in the context of these products. Few nominally significant differences emerged between healthcare professionals from different specialities or regions. Conclusion: In conclusion, this large survey of attitudes held by healthcare professionals towards cannabis-based products revealed a high level of interest and a demand for more information. Limitations of this study include potential sample bias and limited external validity. [ABSTRACT FROM AUTHOR]

Background: The Assessment of Burden of Chronic Conditions (ABCC-)tool is developed to facilitate a personalized approach to care in the patient-healthcare provider (HCP) conversation based on shared decision-making and individualized care plans. An effectiveness study highlighted its effect on the perceived quality of care and patient activation. Successful implementation of novel interventions necessitates an understanding of the user's actual application, user experiences and an evaluation of implementation outcomes. This study aims to evaluate the implementation of the ABCC-tool by HCPs in Dutch primary care. Methods: This study is the process evaluation of a larger type 1 effectiveness-implementation hybrid trial. Semi-structured interviews with HCPs, who were interventionists in the hybrid trial, were held at three and twelve months after they started using the ABCC-tool. The Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) framework was used to evaluate implementation outcomes. The Implementation domain was further strengthened with an evaluation of implementation fidelity using Carroll's framework. Inductive coding and thematic analysis were applied to identify relevant participant experiences and implementation outcomes within the RE-AIM framework. Results: Seventeen HCPs (1 general practitioner, 16 practice nurses) participated in the study, representing 39% of potentially eligible participants. Most HCPs applied the tool after finishing their own routines instead of how it is intended to be used, namely from the beginning of the consultation. HCPs reached 2–6 patients. The ABCC-tool was initially adopted, but twelve HCPs stopped using the tool due to COVID-19 related cancellation of consultations. High fidelity was found for applying the questionnaire and visualization. Low fidelity was present for applying shared decision-making, formulating care goals and monitoring progress. HCPs indicated that maintaning the ABCC-tool depended on accompanying training and implementation support. Conclusions: HCPs applied the ABCC-tool critically different from intended, potentially diminishing its benefits and ease of use. This evaluation stresses the need for a tailored implementation plan that includes more detailed training and guidance on how and when to use the ABCC-tool. Contributions to the literature: Fidelity is an important mediator of an intervention's perceived benefit and implementation success. This evaluation stresses the need for clear training and guidance on using the ABCC-tool. This type 1 effectiveness-implementation hybrid trial confirms the essential role of a thorough implementation plan when implementing the ABCC-tool in Dutch primary care. Implementation plans should include tailored strategies based on contextual influences and local needs of implementers. [ABSTRACT FROM AUTHOR]

Background: Diagnoses entered by general practitioners into electronic medical records have great potential for research and practice, but unfortunately, diagnoses are often in uncoded format, making them of little use. Natural language processing (NLP) could assist in coding free-text diagnoses, but NLP models require local training data to unlock their potential. The aim of this study was to develop a framework of research-relevant diagnostic codes, to test the framework using free-text diagnoses from a Swiss primary care database and to generate training data for NLP modelling. Methods: The framework of diagnostic codes was developed based on input from local stakeholders and consideration of epidemiological data. After pre-testing, the framework contained 105 diagnostic codes, which were then applied by two raters who independently coded randomly drawn lines of free text (LoFT) from diagnosis lists extracted from the electronic medical records of 3000 patients of 27 general practitioners. Coding frequency and mean occurrence rates (n and %) and inter-rater reliability (IRR) of coding were calculated using Cohen's kappa (Κ). Results: The sample consisted of 26,980 LoFT and in 56.3% no code could be assigned because it was not a specific diagnosis. The most common diagnostic codes were, 'dorsopathies' (3.9%, a code covering all types of back problems, including non-specific lower back pain, scoliosis, and others) and 'other diseases of the circulatory system' (3.1%). Raters were in almost perfect agreement (Κ ≥ 0.81) for 69 of the 105 diagnostic codes, and 28 codes showed a substantial agreement (K between 0.61 and 0.80). Both high coding frequency and almost perfect agreement were found in 37 codes, including codes that are particularly difficult to identify from components of the electronic medical record, such as musculoskeletal conditions, cancer or tobacco use. Conclusion: The coding framework was characterised by a subset of very frequent and highly reliable diagnostic codes, which will be the most valuable targets for training NLP models for automated disease classification based on free-text diagnoses from Swiss general practice. [ABSTRACT FROM AUTHOR]

Introduction: Physicians working in primary health care (PHC) centers are the first contact for patients and expected to deal with emergencies. Emergency care training in PHC settings has been neglected globally, especially in low to middle income countries. Adequate preparation becomes especially important during periods of conflict. The study objectives are to identify the barriers facing PHC physicians when dealing with emergency cases in the northern region of Palestine during the current conflict. Methods: A cross-sectional study was conducted with 179 physicians working in the 10 PHC centers distributed among 5 northern governances in Palestine. The study period was from July through December 2023. Data were collected electronically using a self-administered questionnaire, which was adapted from a comprehensive literature review. The questionnaire's internal validity was confirmed by a Cronbach's alpha coefficient of [0.85], indicating high reliability. Results: The ages of the physicians ranged from 25 to 60 years, with a mean ± SD of 35.3 ± 8.15 years. A significant majority (91.6%) were not boarded in any specialty. Most physicians (85.5%) had attended Basic Life Support (BLS) courses, whereas 45.2% and 72% had never attended Advanced Cardiovascular Life Support (ACLS) or Advanced Trauma Life Support (ATLS) courses, respectively. Physicians with emergency department experience (P = 0.002) and those who had attended ACLS courses (P < 0.001) reported significantly higher perceived competence in managing emergency cases. Conclusion: Emergency services at PHC centers in northern Palestine are operational but require significant enhancements. There is a critical need for increased availability of essential equipment, supplies, and medications. Additionally, implementing comprehensive training programs in emergency management, particularly ACLS, is essential to improve the competence and performance of PHC physicians in emergency situations. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic changed the healthcare system, leading to the rapid evolution and implementation of telemedicine (TM). TM has the potential to improve the quality of primary health care and increase accessibility for the population. However, its use may represent challenges for older people, as they may have distinct needs from the general population due to age-related changes in perceptual, motor, and cognitive capacities. We, thus, aimed to identify potential facilitators and barriers to TM use in primary care for older adults and develop recommendations accordingly. Methods: We conducted a qualitative study to explore the challenges associated with TM use among older adults and healthcare professionals (HCPs) in primary care practice. Interviews were conducted with 29 older adults, and three focus groups involving HCPs from four McGill family medicine sites were organized. Employing a hybrid codebook thematic analysis, guided by the Consolidated Framework for Implementation Research (CFIR), we identified facilitators and barriers affecting the optimal use of TM by older adults and HCPs. We synthesized the results from semi-structured interviews and focus groups. These findings were then presented during a deliberative dialogue with eight participants, including family physicians, nurses, a social worker, and a government-level TM expert, to validate our results. The purpose was to gather feedback, identify and refine actionable recommendations. Subsequently, we utilized a thematic analysis using the same codebook to synthesize findings from the deliberative dialogue. Results: Participants agreed that TM contributed to maintaining the continuity of care and was particularly convenient when there was an existing or established patient-physician relationship or for addressing minor health issues. TM was found to be beneficial for people with limited mobility, reducing their exposure to potentially high-risk environments. However, participants expressed concerns about the lack of visual contact, causing essential details to be overlooked. Additionally, issues related to miscommunication due to language or hearing barriers were identified. HCPs perceived that most older adults did not consider phone consultations a medical act. Participants were open to a hybrid approach, combining in-person consultations and TM, based on their specific health conditions. Building upon these results, we formulated seven key recommendations. Conclusions: Both older adults and HCPs consider TM a good alternative for accessing healthcare services. To improve the effective use of TM, it's crucial to advocate for a hybrid approach that integrates both in-person and virtual methods. This approach should actively encourage and support individuals in becoming familiar with technological tools. [ABSTRACT FROM AUTHOR]

Objectives: Individuals who die by suicide often consult their general practitioners (GPs) in their final weeks of life. The aim of this study was to gain a deeper knowledge of the clinical characteristics and GP assessments and treatments among individuals who consulted their GPs during the month preceding suicide. Further, we compared these features in those with and without contact with psychiatric services (PC and NPC, respectively) during the two years that preceded the suicide. Design: A nationwide retrospective explorative study investigating medical records. Setting: Primary care in Sweden. Participants: Individuals who died by suicide in Sweden in 2015 with a GP visit within 30 days of death. Results: The study cohort corresponds to one fifth (n = 238) of all suicides that occurred in Sweden in 2015 (n = 1179), representing all those with available primary care records showing contact with a GP during the final 30 days of life (NPC: n = 125; PC: n = 113). The mean age was 58 years ± 19. Patients in the NPC group were older (NPC: 63 years ± 19 vs. PC: 53 years ± 18, p < 0.0001) and presented psychiatric symptoms less often (NPC: 50% vs. PC: 67%, p < 0.006). Somatic symptoms were as common as psychiatric symptoms for the whole sample, being present in more than half of individuals. Suicide risk was noted in only 6% of all individuals. Referral to psychiatric services occurred in 14%, less commonly for the NPC group (NPC: 6% vs. PC: 22%, p < 0.001). Cardiovascular or respiratory symptoms were noted in 19%, more often in the NPC group (NPC: 30% vs. PC: 6%, p < 0.001), as were diagnoses involving the circulatory system (all 10%, NPC:14% vs. PC: 5%, p < 0.020). Conclusion: A high level of somatic symptoms was observed in primary care patients both with and without psychiatric contact, and this might have influenced GPs' management decisions. Psychiatric symptoms were noted in two thirds of those with psychiatric contact but only half of those without. While GPs noted psychiatric symptoms in over half of all individuals included in the study, they seldom noted suicide risk. These findings highlight the need for increased attention to psychiatric symptoms and suicide risk assessment, particularly among middle-aged and older individuals presenting with somatic symptoms. Strengths and limitations of this study: The National Cause of Death Register has excellent coverage of suicide deaths and access to medical records was very good. The medical record review provided detailed information regarding primary care utilization before death by suicide. Because of the lack of statistical power, due to the limited number of persons with GP contact during the last month of life, we chose not to correct for multiple comparisons. Our study approach did not capture the reasons behind GPs' documentation of elevated suicide risk. No systematic inter-rater reliability (IRR) testing was made, however, reviewers received training and continuous support from the research group. [ABSTRACT FROM AUTHOR]

Background: Eating disorders (EDs) are serious mental health conditions that affect a person physically and psychologically. In the past, EDs were only recognized as a cultural phenomenon/societal by-product of the West. However, research evidence marks its presence in non-western countries also, including South Asia. This study aims to evaluate the feasibility and acceptability of a manualized psychological intervention called Getting Better Bite by Bite (GBBB) in individuals who screened positive on measures of EDs in Pakistan. Methods: The proposed study is a feasibility randomized controlled trial (fRCT). The study will be conducted at five sites across Pakistan: Karachi, Hyderabad, Lahore, Rawalpindi, and Multan to recruit a total of 80 participants. Eligible participants will be randomized to either (1) the intervention group; in which they will receive one-to-one sessions of GBBB along with routine care or (2) the routine care group; in which they will only have access to the routine care. We have received ethics approval by the National Bioethics Committee. The study is registered at clinicaltrials.gov (NCT05724394). The study team has received permission from recruitment centers: hospitals (i.e. the psychiatry department of public and private hospitals based in these cities), fitness centers (i.e., gyms), educational institutes (i.e., colleges and universities), and community settings (i.e. community health clinics). Self-referrals from General Practitioners and community settings will be accepted. The intervention manual has been translated into Urdu and a multidisciplinary team including service users has culturally adapted the content of intervention for local context. Discussion: This study will provide evidence on feasibility and acceptability of a culturally adapted intervention for individuals who screen positive on measures of EDs. The findings of this study will inform a fully powered Randomized Controlled Trial of the proposed intervention. Trial Registration. The study is registered on clinicaltrials.gov (NCT05724394). Protocol version (1.0. 1st June 2022). [ABSTRACT FROM AUTHOR]

Introduction: Non-ophthalmologists often lack sufficient operational training to use a direct ophthalmoscope proficiently, resulting in a global deficit of basic ophthalmological skills among general practitioners. This deficiency hampers the timely diagnosis, referral, and intervention of patients. Consequently, the optimization of teaching tools and methods to enhance teaching efficiency is imperative. This study explores the effectiveness of the Eyesi Direct Ophthalmoscope Simulator (Eyesi) as an innovative tool for fundus examination training. Methods: Medical undergraduates were randomly assigned to Group A or B (n = 168). All participants completed a pre-training questionnaire. Group A received Eyesi training, while Group B underwent traditional direct ophthalmoscope (TDO) training. Subsequently, participants answered questionnaires relevant to their respective training methods. Both groups exchanged training tools and completed a summary questionnaire. Results: After training, 54.17% of participants believed that images presented by the Eyesi were consistent with the real fundus. Group A scored significantly higher than Group B in fundus structure recognition and self-confidence in examination. The degree of mastery over fundus theory score increased from 6.10 ± 0.13 to 7.74 ± 0.16 (P < 0.001) in Group A, but Group B did not demonstrate a significant difference. We also compared undergraduates' tendencies for different learning purposes, 75.59% of participants preferred the Eyesi to TDO as a training tool, and 88.41% of participants were receptive to introducing the Eyesi in training. Conclusion: According to subjective participant feedback, Eyesi outperformed TDO in fundus observation, operational practice, and theoretical learning. It effectively equips undergraduates with fundus examination skills, potentially promoting the use of direct ophthalmoscopes in primary medical institutions. [ABSTRACT FROM AUTHOR]

Objective: To explore the application effect of mini clinical evaluation exercise (Mini-CEX) combined with direct observation of procedural skills (DOPS) in the standardized training of general practitioners in community clinics. Methods: From June 2022 to June 2023,20 general practitioners who received standardized training for residents in the general outpatient department of Changqing Community Health Service Center of Wuhan Fourth Hospital were collected as the research objects. Mini-CEX combined with DOPS was used to evaluate the general practitioners at the time of admission, 2 weeks of training and 4 weeks of training, and the results were fed back. Results: The scores of 20 general practitioners at 2 weeks and 4 weeks of training were compared with the scores at the time of admission, and the difference was statistically significant, p < 0.05. Conclusion: Mini-CEX combined with DOPS can improve the teaching effect of standardized training of residents in community general clinics. [ABSTRACT FROM AUTHOR]

Background: Cancer patients report that they lack support from healthcare providers when it comes to returning to or maintaining employment. In the education of general practitioners (GPs) in the Netherlands, there is little attention given to discussing work participation with patients. The aim of this pilot study was to evaluate a newly developed education program for GPs in training that focuses on discussing work participation with cancer patients. Methods: Two groups of in total twenty-one GPs in training participated in the education program. GPs were educated about the importance of discussing work participation with patients, work-related problems cancer patients can experience, and advice they can give to support cancer patients regarding work issues. In this pilot study using a mixed-method design, participants evaluated the program in two self-developed questionnaires and in a focus group discussion. Results: Seventeen participating GPs (81%) indicated that the education program was suitable for implementation in the education curriculum. Eleven participants (52%) reported that they had never discussed work participation with cancer patients before. Directly after the education program, eighteen participants (86%) reported that they planned to discuss work participation more often with their patients. Four months after the program, 67% indicated they had applied their new knowledge and skills in practice by discussing work participation and by referring cancer patients to occupational health professionals or online resources. According to the GPs in training, integrating the topic of work participation into other education for GPs in training and focusing on a broader group of patients could improve the impact of the education program. Conclusions: According to the results of this pilot study, the newly developed education program increased the awareness of GPs in training on the importance of discussing work participation with cancer patients. Future studies should focus on whether cancer patients experience more support from their GPs for maintaining and returning to employment after their GP has participated in the training program. [ABSTRACT FROM AUTHOR]

Background: General practice is often recommended as an ideal setting to initiate advance care planning (ACP), but uptake of ACP in this setting is low. ACP-GP is a complex intervention to facilitate ACP for patients with chronic, life-limiting illness in Belgian general practice. It aims to increase patient ACP engagement and general practitioner (GP) ACP self-efficacy. In a cluster-randomized controlled trial, the intervention was not superior to control in increasing these outcomes. A parallel process evaluation aimed to enhance understanding of how the intervention was implemented, and which factors might have influenced trial results. Methods: We conducted a mixed-methods process evaluation following the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Data sources include recruitment and implementation monitoring, questionnaires for patients and GPs, and semi-structured (focus group) interviews with patients and GPs. Questionnaire data were analyzed descriptively. Qualitative data were first analyzed inductively; themes were then assigned deductively to RE-AIM dimensions. Results: Thirty-five GPs and 95 patients were recruited to the trial; GP reach was low. Sixteen GPs and 46 patients provided questionnaire data at 3 months post-baseline; qualitative data were transcribed for 14 GPs and 11 patients. Adoption of intervention components was moderate to good, with the exception of the documentation template for GPs. Interviews revealed varying patient attitudes towards ACP, but patients nonetheless emphasized that conversations made them feel reassured. GPs especially valued a positive framing of ACP. When adopted, the intervention was well-implemented and participant satisfaction was high. However, intention for maintenance was moderate, with GPs raising questions of how to sustainably implement ACP conversations in the future. Conclusions: Implementing the complex ACP-GP intervention in general practice is feasible, and can be successful. However, the implementation process is challenging and the sustainability is suboptimal. Our findings will guide future research and recommendations for facilitating and implementing ACP in general practice. Trial registration: ISRCTN12995230; prospectively registered on 19/06/2020. [ABSTRACT FROM AUTHOR]