जनरल प्रैक्टिस जर्नल

Background: Canadian mental health care reform calls for new service delivery models that capitalize on health promotion, support and early intervention as patients and services are transitioning from institutions to communities. The Mental Health Engagement Network (MHEN) intervention is a smart technology enabled service delivery model that electronically links individuals to their health care professionals, promoting information sharing between individuals and their health care professionals, and promoting access to mental health care services. This project, funded by Canada Health Infoway, began in September 2011 and will complete in March 2013. Methods: The MHEN project is a longitudinal, mixed qualitative and quantitative research study which has recruited 400 (245 men and 155 women) research participants diagnosed with a mood or a psychotic disorder who are currently working with community based mental health care professionals (54 mental health care professionals across 4 agencies in the London and surrounding area). Each participant has been randomly assigned into Group 1 (early intervention) or Group 2 (later intervention). Group 1 participants received an iPhone 4S, a TELUS health space™ account, and version 1.0 of the Lawson SMART record (a web-based application that provides individuals with a personal health record and tools to help them manage their health) in July, 2012. Participants in Group 2 initially acted as a control group, and received the version 2 intervention in March, 2013. Results: Participants felt the Lawson SMART record was quite (33.1%) or extremely (29.2%) helpful, and gave participants quite a bit more (26.8%) and an extreme amount more (21%) independence. Web analytics demonstrated that participants visited the Lawson SMART record mobile and desktop home page a total of 16, 928 times. Conclusion: This new service delivery model has the potential to provide quality care to those living in the community with mental illness, enhance health status and quality of life, and reduce the burden of mental illness on the healthcare system by decreasing more costly service uses.

T wave inversions on an electrocardiogram (EKG) can manifest from any process that result in a relative delay in regional ventricular repolarization. The differential diagnosis of right precordial T wave inversions, leads V1-V3, include myocardial ischemia, a normal athlete’s heart, arrhythmogenic right ventricular dysplasia, and pulmonary embolism amongst others. The case discussed below is of a 73 year old man who presented to a cardiologist with chest pain and shortness of breath. He had an initial ECG that showed a normal sinus rhythm with T wave inversions across the right precordial leads. He had an unrevealing coronary angiogram and an echocardiogram that only showed right-sided strain. Thereafter, he had a ventilation perfusion scan, which diagnosed pulmonary embolus. He was treated with anticoagulation and his symptoms resolved. The present case delineates the importance of recognizing this ECG pattern and, in the correct clinical setting, can facilitate in diagnosis and treatment of a relatively common medical condition.

Background: The Strategies and Opportunities to Stop Colorectal Cancer (STOP CRC) study is collaboration among two research institutions and health-systems partners. The main study, scheduled to begin in 2014, will assess effectiveness of an intervention program using electronic health record (EHR) clinical decision support (CDS) tools to improve rates of colorectal-cancer screening in federally qualified health centers (FQHCs). Very few studies, and no large studies, aimed at raising CRC screening rates have utilized an EHR-embedded system. Study design: We piloted the use of an EHR-embedded real-time patient registry reporting tool in a pilot study undertaken prior to beginning our main CRC screening study. The pilot study goal was to assess feasibility and effectiveness of two clinic-based approaches to raising rates of colorectal cancer screening among selected patients aged 50-74 who were not up-to-date with colorectal-cancer screening guidelines. We used work sessions and qualitative interviews with clinic personnel to assess performance of the tool, as well as to identify specific elements of the tool’s functionality needing refinement. Results: Two critical elements of the EHR tool allowed us to mail FIT kits efficiently to appropriate patients: (1) having a direct interface with the laboratory that processed the FITs, thus allowing for real-time updates to the registry; and (2) being able to place lab orders from a list of selected patients. We identified the following elements that needed refining: the use of Health Maintenance (EHR function for tracking screening eligibility and due dates incorporating STOP CRC inclusion and exclusion criteria), and the development of report templates for identifying patients eligible for each step. Conclusion: We found that most elements of our EHR-embedded program worked well and that specific refinement may improve the accuracy of identifying patient

Abstract Background: The primary purpose of pre-participation screening is identifying the cohort of athletes affected by unsuspected cardiovascular diseases, such as coronary artery disease (CAD) as well as preventing sudden cardiac death (SCD) during sports competitions or training, through appropriate intervention. Case Report: This case report describes the recent history of a middle-aged marathon runner suffering from asymptomatic ischemic heart disease at high risk for SCD and illustrates the clinical pathway. An exercise ECG stress testing was positive for subendocardial ischemia. Computerized tomography (CT) coronary angiogram subsequently showed critical narrowing of the left anterior descending artery. Invasive coronary angiography was performed following angioplasty procedure. One month later an exercise ECG stress testing was normal, indicative of complete myocardial revascularization. Conclusions: Silent myocardial ischemia (SMI) is not such a rare event in athletes, especially in endurance sports athletes. In fact, even though they are asymptomatic this does not exclude the presence of a severe coronary artery disease. Exercise stress testing is safe and affordable non-invasive screening for detecting asymptomatic coronary artery disease in athletes. Myocardial revascularization procedure is to re-establish the athlete’s state of fitness for competitive sports.

Background: Menstruation is the periodic and cyclical discharge of blood, mucus and cellular debris from the uterine mucosa, which occurs due to progesterone withdrawal after ovulation in non-fertile cycles. Menstruation and menstrual practices are still clouded by taboos and socio-cultural restrictions resulting in adolescent girls remaining ignorant of the scientific facts and hygienic health practices, which sometimes result into adverse health outcomes. Aim: To determine the level of knowledge of adolescent females about menstrual cycle and their practice and restrictions during menstruation. Subjects and method: A descriptive cross sectional study was conducted to involve 1084 female students aged 15-21 years in Baghdad from 10 randomly selected secondary schools in different districts of Baghdad during the period April the 10th through May using direct interview questionnaire, each student was interviewed separately & privately, scoring for knowledge was calculated using Excel, and knowledge was classified as good or poor. Results: Good knowledge had been seen in 36% of them, as the mothers formed the major source of knowledge (74%), Food quantity or quality during menstruation was not changed in 38%, while 21% of girls consume fruit & vegetables during menstruation. 84.2% of the girls restrict their physical activity while menstruating. 22.6% of the girls did not take a bath during menstruation at all while 13.3% took bath after the 1st day. Analgesics were used without prescription in 54% of the girls during menstruation, 14% required medical help for various menstrual causes and Absenteeism from school from 23.6% from total. Conclusion: The knowledge regarding menstruation was poor in the majority of the girls, and mothers were their major source of information, certain practices were restricted during menstruation such as bathing and physical activity and absenteeism from school was considerable.

Researchers have been increasingly interested in the influence of computers on physician-patient communication in consultation rooms because of the substantial growth in the use of Electronic Health Records (EHRs) in the U.S. Previous research showed that physicians have different ways of interacting with patients and EHRs; and these styles may relate to different patterns of nonverbal interaction between the physicians and patients and influence the outcomes of the clinical visit. The purpose of this study was to identify the differences of eye gaze patterns in three EHR interaction styles: the technology-centered style, the human-centered style, and the mixed interaction style. 100 primary care visits with different interaction styles were videotaped. Eye gaze behaviors were coded and described as frequencies and durations of gaze. The dynamic eye gaze patterns of the physicians and patients, in terms of how their gaze behaviors were sequentially associated, were analyzed using lag-sequential analysis. The results indicated that technology-centered group had significantly shorter amount of mutual gaze than other two groups (p=0.032; p=0.015, respectively). In addition, in technology centered style, the physicians were more likely to shift their gaze to the computer when the patients gazed at them; and when the physicians gazed at the computers, the patients were more likely to gaze somewhere else which might be an indicator of disengagement. The study implied that EHRs should be designed in a way that facilitates a positive interaction between the physicians and patients, such as maintaining mutual gaze. Training should also be provided to the physicians for establishing effective and positive interaction styles.

Our current society is a consumption information society where attention is turned towards the epistemological aspect of the data and information as such predominates. In the medium term, this society has become a communication information society focused on information exchange and sharing human. In other words, it must be based on the relationship and not on information from real people. This anthropological vision is essential for converting information into knowledge. A neo-platonic ethics systemic approach highlights a pyramidal representation of knowledge that reflects the evolution of our society healthy from Medicine 1.0 to tend towards Medicine 4.0.

Background: The Consultation is of immense importance in primary care. This study aimed to utilize physician attributes in the patient-care process in determining the proportion of patients who were satisfied or otherwise with the consultation at their doctor-patient interaction. Method: This was a cross-sectional descriptive study undertaken in the Family Medicine Clinic of the University of Calabar Teaching Hospital in the Niger Delta Region of Nigeria. A modified post consultation version of the General Practice Assessment Questionnaire was administered to 430 patients aged 18 to 67 years, who were selected through a process of systematic random sampling over a period of three weeks. Data generated in this study was analyzed using the statistical package for social sciences version 11. Results: Of the 430 subjects studied, 46.74% were males and 53.26% females. The physician attributes shown to positively affect patients’ satisfaction with the consultation included: manner of asking the patients about their feeling regarding their illnesses, detailed enquiry about the patients’ symptoms, discussing the origin of the patients’ illnesses, involving the patients in decisions about the care and explaining the patients’ problems and any treatment needed. Others were: making the patients feel at ease during the examination, showing care and concern and addressing their main presenting problems. Conclusion: The study demonstrated clearly that physician attributes greatly influence the outcome of the Consultation in Primary Care.

Background: The Objective Structured Clinical Examination was designed 30 years ago by Harden ea. It is used to assess various components of medical competence. The OSCE is considered as a reliable and objective tool to evaluate clinical competences in standardized patient encounters. Although, reliability, validity and reproducibility an OSCE remain subject of debate. These days the question arises if a compensatory or an additional rating is advisable for the final pass-fail decision. Aim: The aim of the study is to add to the identification of high risk postgraduate trainees in general practice by means of ‘a yellow card system’ (red flagging). Method: During 8 OSCE-sessions, including 354 GP-trainees, observers were asked to deal a yellow card in case of ‘alarming performance’. These acts were defined as dramatic or dangerous shortcomings on three levels: theoretical, practical and behavioral level. Result: During three academic years, involving 354 trainees, only 41 yellow cards were dealt. One single observer was responsible for one quarter of all allocations. During two sessions half of all cards were dealt. Trainees remembered with a yellow card were more likely to underperform on all assessments except on the internship. During their internships, trainees with a yellow card did not show remarkable or alarming behavior. Conclusion: Flagging alarming events during the OSCE does not identify high risk trainees. The idea of ‘flagging’ is not be abandoned but moved to other assessment situations