Managing the transition to non-driving in patients with dementia in primary care settings: facilitators and barriers reported by primary care physicians.

OBJECTIVES: This research addresses dementia and driving cessation, a major life event for affected individuals, and an immense challenge in primary care. In Australia, as with many other countries, it is primarily general practitioners (GPs) who identify changes in cognitive functioning and monitor driving issues with their patients with dementia. Qualitative evidence from studies with family members and other health professionals shows it is a complicated area of practice. However we still know little from GPs about how they manage the challenges with their patients and the strategies that they use to facilitate driving cessation. METHODS: Data were collected through five focus groups with 29 GPs at their primary care practices in metropolitan and regional Queensland, Australia. A semi-structured topic guide was used to direct questions addressing decision factors and management strategies. Discussions were audio recorded, transcribed verbatim and thematically analyzed. RESULTS: Regarding the challenges of raising driving cessation, four key themes emerged. These included: (i) Considering the individual; (ii) GP-patient relationships may hinder or help; (iii) Resources to support raising driver retirement; and (iv) Ethical dilemmas and ethical considerations. The impact of discussing driving cessation on GPs is discussed. CONCLUSIONS: The findings of this study contribute to further understanding the experiences and needs of primary care physicians related to managing driving retirement with their patients with dementia. Results support a need for programs regarding identification and assessment of fitness to drive, to upskill health professionals and particularly GPs to manage the complex issues around dementia and driving cessation, and explore cost-effective and timely delivery of such support to patients.

Protocol: Using N-of-1 tests to identify responders to melatonin for sleep disturbance in Parkinson's disease.

BACKGROUND: 40% of Parkinson's Disease (PD) sufferers experience insomnia, impacting health and quality of life for patients and family members, especially carers. There is little evidence that current treatments are effective. OBJECTIVES: To determine the effectiveness of melatonin in reducing insomnia in 44 individuals with PD using N-of-1 trials. To aggregate group data to arrive at population estimates of effectiveness (measured by improvements in PDSS-2) and safety (measured by adverse events) of melatonin in improving insomnia in PD. To assess the feasibility of offering N-of-1 trials for insomnia in PD. METHODOLOGY: Participants will receive either immediate-release melatonin or placebo in random order in 3 paired two-week treatment periods (12 weeks total). Based on their response in a two-week run-in period on 3 mg daily, they will trial either 3 mg or 6 mg. Patients will keep daily sleep diaries and wear a MotionWatch throughout. After the trial patients will discuss their individual report with their doctor, which provides direct feedback about effectiveness and safety of melatonin for them. STATISTICAL METHODS: We will analyse N-of-1 tests 1) individually: effects of melatonin on PDSS-2 and safety will be reported; and 2) aggregated across individual N-of-1 studies, combined using a Bayesian multilevel random effects model, which will account for repeated measures on individuals over time, and will return posterior estimates of overall treatment effect, and effect in each individual. CLINICAL TRIAL REGISTRATION NUMBER: ACTRN12617001103358.

Single-center retrospective study of the technique, safety, and 12-month efficacy of the MiniArc™ single-incision sling: a new minimally invasive procedure for treatment of female SUI.

This study was conducted to report on the technique, safety, and early efficacy of a single-incision mini-sling to treat female stress urinary incontinence (SUI). Women suffering from SUI were offered a single-incision approach to place a suburethral polypropylene mesh tape in a position similar to that of a transobturator sling without passage of needles through the groin. Retrospective data was collected on 61 patients that received the new MiniArc™ single-incision sling at a single center in the United States. Patient selection and concomitant procedures were determined by the senior authors at the center, and the senior authors were the primary surgeons in all cases. Procedures were completed under general, regional, or MAC anesthesia as determined by the surgeon. Average operative time for the sling procedure alone was short and the average blood loss was 29 cc. There were no intraoperative complications. There was one postoperative adverse event secondary to urinary retention that was resolved by loosening of the sling under local anesthesia in an office setting. The overall cure rate at 12 months determined by physician and patient assessment in 58/61 patients was 91.4%. No patients suffered pain or dyspareunia secondary to the sling, and no erosions or extrusions were reported. In this initial study, the MiniArc™ single-incision sling appears to be a safe approach to treat female SUI, and the early clinical results are encouraging.

Do case conferences between general practitioners and specialist palliative care services improve quality of life? A randomised controlled trial (ISRCTN 52269003).

Australian palliative care is delivered by general practitioners (GPs) and specialist palliative care teams. Patient outcomes should improve if they work in formal partnership. We conducted a multi-centred randomised controlled trial of specialist- GP case conferences, with the GP participating by teleconference, or usual care and communication methods. Primary outcome measure was global Quality of Life (QoL) scores at 3 weeks from intervention. Secondary measures included subscale QoL scores and carer burden. Two a priori intention-to-treat analyses were conducted using recruitment, and time of death, as fixed time points. There was no difference between groups in the magnitude of change in global QoL measures from baseline to any time point up to 9 weeks post-case conference, or at any time before death. The case conference group showed better maintenance of some physical and mental health measures of QoL in the 35 days before death. Case conferences may improve clinical relationships and care plans at referral, which are not implemented until severe symptoms develop. Case conferences between GPs and specialist palliative care services may be warranted for palliative care patients.

Attitudes and practices of general practitioners in the diagnosis and management of attention-deficit/hyperactivity disorder.

OBJECTIVE: To assess understanding of, and actual and potential roles in management of attention-deficit/hyperactivity disorder (ADHD) among GPs. METHODS: A cross-sectional questionnaire survey of Queensland GPs selected randomly from the Royal Australian College of General Practitioners directory of members was carried out. Main outcome measures were knowledge levels of ADHD, current management practices, referral patterns and self-perceived information and training needs. RESULTS: Three hundred and ninety-nine GPs returned a completed questionnaire (response rate 76%). Roles identified by GPs were: the provisional diagnosis of ADHD and referral to specialist services for confirmation of the diagnosis and initiation of management; assistance with monitoring progress once a management plan was in place; education of the child and their family regarding the disorder; and liaison with the school where necessary. Perceived barriers to increased involvement of GPs were: time and resource constraints of general practice; concerns regarding abuse and addiction liability of prescription stimulants; complex diagnostic issues associated with childhood behavioural problems; and lack of training and education regarding ADHD. CONCLUSIONS: General practitioners identify a role for themselves in ADHD care that is largely supportive in nature and involves close liaison with specialist services.

Amine-specificity of the inactivating ornithine decarboxylase modification in Physarum polycephalum.

The enzyme catalysing the polyamine-stimulated modification of Physarum ornithine decarboxylase in vivo was partially purified and its activity on purified ornithine decarboxylase was examined with respect to its specificity for various amines. Spermidine, spermine and several polyamine analogues strongly promoted this reaction in vitro (apparent Km in the 0.1--0.5 mM range), whereas putrescine (apparent Km 5.33 mM) and several related diamines were not nearly as effective. In agreement with this, sensitivity studies performed in vivo also suggested that cellular spermidine, and not putrescine, is critical in modulating ornithine decarboxylase activity by this post-translational control. Unlike putrescine, or other diamines, 1,3-diaminopropane demonstrated a functional similarity to the polyamines in stimulating this reaction. This study has demonstrated a method whereby non-physiological amines capable of depressing ornithine decarboxylase activity by this natural feedback mechanism can be readily identified for further evaluation of their potential use in the experimental and medical control of polyamine biosynthesis.