Acting as standardized patients enhances family medicine residents' self-reported skills in palliative care.

Recent publications have confirmed the use of standardized patients (SPs) in improving clinical skills and enhancing competency. Little research has studied the benefits residents may themselves gain in palliative care playing the role of SPs. Nineteen Family Medicine residents were recruited as standardized patients (FMR-SPs) for a mandatory palliative care workshop in communication for incoming, first-year trainees. Four months later, FMR-SPs reflected upon their own experiences. Two independent researchers performed thematic analysis of these interviews. Most of the residents were satisfied with their roles. Twelve reported improved understanding of self, their patients, the doctor-patient relationship, and the underlying philosophy of palliative care. They also described improved verbal and non-verbal communication skills. Eleven of 14 residents reflected upon behavioral changes in problem coping styles. All residents indicated an intention to apply the learning in their future work. Encouraging Thai Family Medicine residents, in years one through three, to portray SPs in palliative care appears to be a valuable learning experience for the resident. Future studies to validate whether this learning has been applied in subsequent practice are planned.

Situational analysis of palliative care education in thai medical schools.

OBJECTIVE: The Thai Medical School Palliative Care Network conducted this study to establish the current state of palliative care education in Thai medical schools. METHODS: A questionnaire survey was given to 2 groups that included final year medical students and instructors in 16 Thai medical schools. The questionnaire covered 4 areas related to palliative care education. RESULTS: An insufficient proportion of students (defined as fewer than 60%) learned nonpain symptoms control (50.0%), goal setting and care planning (39.0%), teamwork (38.7%), and pain management (32.7%). Both medical students and instructors reflected that palliative care education was important as it helps to improve quality of care and professional competence. The percentage of students confident to provide palliative care services under supervision of their senior, those able to provide services on their own, and those not confident to provide palliative care services were 57.3%, 33.3%, and 9.4%, respectively. CONCLUSIONS: The lack of knowledge in palliative care in students may lower their level of confidence to practice palliative care. In order to prepare students to achieve a basic level of competency in palliative care, each medical school has to carefully put palliative care content into the undergraduate curriculum.

Aspirin, steroidal and non-steroidal anti-inflammatory drugs for the treatment of Alzheimer's disease.

BACKGROUND: Alzheimer's disease (AD) is the most common form of dementia. The incidence of AD rises exponentially with age and its prevalence will increase significantly worldwide in the next few decades. Inflammatory processes have been suspected in the pathogenesis of the disease. OBJECTIVES: To review the efficacy and side effects of aspirin, steroidal and non-steroidal anti-inflammatory drugs (NSAIDs) in the treatment of AD, compared to placebo. SEARCH METHODS: We searched ALOIS: the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 12 April 2011 using the terms: aspirin OR "cyclooxygenase 2 inhibitor" OR aceclofenac OR acemetacin OR betamethasone OR celecoxib OR cortisone OR deflazacort OR dexamethasone OR dexibruprofen OR dexketoprofen OR diclofenac sodium OR diflunisal OR diflusinal OR etodolac OR etoricoxib OR fenbufen OR fenoprofen OR flurbiprofen OR hydrocortisone OR ibuprofen OR indometacin OR indomethacin OR ketoprofen OR lumiracoxib OR mefenamic OR meloxicam OR methylprednisolone OR nabumetone OR naproxen OR nimesulide OR "anti-inflammatory" OR prednisone OR piroxicam OR sulindac OR tenoxicam OR tiaprofenic acid OR triamcinolone OR NSAIDS OR NSAID. ALOIS contains records of clinical trials identified from monthly searches of a number of major healthcare databases (including MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS), numerous trial registries (including national, international and pharmacuetical registries) and grey literature sources. SELECTION CRITERIA: All randomised controlled trials assessing the efficacy of aspirin, steroidal and non-steroidal anti-inflammatory drugs in AD. DATA COLLECTION AND ANALYSIS: One author assessed risk of bias of each study and extracted data. A second author verified data selection. MAIN RESULTS: Our search identified 604 potentially relevant studies. Of these, 14 studies (15 interventions) were RCTs and met our inclusion criteria. The numbers of participants were 352, 138 and 1745 for aspirin, steroid and NSAIDs groups, respectively. One selected study comprised two separate interventions. Interventions assessed in these studies were grouped into four categories: aspirin (three interventions), steroids (one intervention), traditional NSAIDs (six interventions), and selective cyclooxygenase-2 (COX-2) inhibitors (five interventions). All studies were evaluated for internal validity using a risk of bias assessment tool. The risk of bias was low for five studies, high for seven studies, and unclear for two studies.There was no significant improvement in cognitive decline for aspirin, steroid, traditional NSAIDs and selective COX-2 inhibitors. Compared to controls, patients receiving aspirin experienced more bleeding while patients receiving steroid experienced more hyperglycaemia, abnormal lab results and face edema. Patients receiving NSAIDs experienced nausea, vomiting, elevated creatinine, elevated LFT and hypertension. A trend towards higher death rates was observed among patients treated with NSAIDS compared with placebo and this was somewhat higher for selective COX-2 inhibitors than for traditional NSAIDs. AUTHORS' CONCLUSIONS: Based on the studies carried out so far, the efficacy of aspirin, steroid and NSAIDs (traditional NSAIDs and COX-2 inhibitors) is not proven. Therefore, these drugs cannot be recommended for the treatment of AD.

Reliability and validity of a Thai version of the edmonton symptom assessment scale (ESAS-Thai).

CONTEXT: The Edmonton Symptom Assessment Scale (ESAS), created by the Edmonton Group in 1991, is an instrument assessing symptom control that is commonly used in palliative care. It asks patients to rate nine items on 11-point numeric rating scales. OBJECTIVES: The aim of this study was to translate the ESAS to Thai and validate its final version with transcultural adaptation for Thai palliative care patients. The original ESAS was translated into Thai following the process of cross-cultural adaptation of self-report measures' standard guidelines, including forward translation, synthesis of the translation, back translation, cross-cultural adaptation, and pretesting. METHODS: This cross-sectional study was first undertaken with 44 patients with advanced cancer in an inpatient setting, which led to the final version. The reliability and validity of the final version was then examined in a sample of 37 cancer patients in the outpatient department at Ramathibodi Hospital. Face validity was evaluated through patient interviews, using guide questions. The internal consistency was calculated using Cronbach's alpha. RESULTS: In total, 91.8% of patients declared that the ESAS-Thai questionnaire was generally clear. It yielded a Cronbach's alpha of 0.75 in the inpatient setting. After modifying the words "appetite" and "well-being," 37 cancer patients, whose mean (standard deviation) age was 52.2 (10.8) years and who were cared for by the Departments of Medicine, Surgery, Gynecology, and Otolaryngology, self-administered the questionnaire in the outpatient department. The Cronbach's alpha in the validation sample was 0.89. CONCLUSION: After the translation and cross-cultural adaptation, the Thai version of the ESAS achieved good levels of face validity and internal consistency. It is now available as a patient-administered instrument to evaluate symptoms among palliative care patients in Thailand.

Patients' experience of oxygen therapy and dyspnea: a qualitative study in home palliative care.

BACKGROUND: Dyspnea is a common and distressing symptom in advanced cancer patients. Our preliminary work shows that in the home palliative care population sampled for this study, the prevalence of dyspnea is 29.5% and of those, 26.2% used oxygen therapy. Previous studies suggested that oxygen therapy can be a burden to patients. PURPOSE: This study seeks to report the prevalence and describe the experience of dyspnea, pattern of oxygen use, and patients' perceived benefits and/or burdens of oxygen therapy in home palliative care patients receiving oxygen therapy. METHODS: Qualitative in-depth interviews, using an interview guide, were conducted with eight participants in their homes. Thematic analysis was performed using a framework approach. RESULTS: All patients in this project used oxygen most of the time. The descriptions of shortness of breath varied and were nonspecific. The patients identified more advantages than disadvantages. The advantages of oxygen use included increased functional capacity, patients' perceiving oxygen as a life-saving intervention, as well as a symptom-management tool. The identified disadvantages were decreased mobility, discomfort related to the nasal prongs, barriers to accessing oxygen therapy and noise related to the equipment. CONCLUSION: The advantages of oxygen usage outweighed the disadvantages for this sample of patients in the home palliative setting.

Does Family Medicine training in Thailand affect patient satisfaction with primary care doctors?

BACKGROUND: Recent national healthcare reforms in Thailand aim to transfer primary care to family physicians, away from more expensive specialists. As Family Medicine has yet to be established as a separate discipline in Thailand, newly trained family physicians work alongside untrained general doctors in primary care. While it has been shown that Family Medicine training programs in Thailand can increase the quality of referrals from primary care doctors to specialists, information is lacking about whether such training affects the quality of patient care. In the Department of Family Medicine at Ramathibodi Hospital, trained family physicians work with residents and general doctors. Although this situation is not typical within Thailand, it offers us the opportunity to look for variations in the levels of satisfaction reported by patients treated by different types of primary care doctor. METHODS: During a two-week period in December 2005, 2,600 questionnaires (GPAQ) were given to patients visiting the Department of Family Medicine at Ramathibodi Hospital. Patients were given the choice of whether or not they wanted to participate in the study. A cross-sectional analysis was performed on the completed questionnaires. Mean GPAQ scores were calculated for each dimension and scored out of 100. Student t-tests, ANOVA with F-test statistic and multiple comparisons by Scheffe were used to compare the perceived characteristics of the different groups of doctors. Five dimensions were measured ranging from access to care, continuity of care, communication skills, enablement (the patient's knowledge of a self-care plan after the consultation) and overall satisfaction. RESULTS: The response rate was 70%. There were significant differences in mean GPAQ scores among faculty family physicians, residents and general doctors. For continuity of care, patients gave higher scores for faculty family physicians (67.87) compared to residents (64.57) and general doctors (62.51). For communication skills, patients gave the highest GPAQ scores to faculty family physicians (69.77) and family medicine residents (69.79). For enablement, faculty family physicians received the highest score (82.44) followed by family medicine residents (80.75) and general doctors (76.29). CONCLUSION: Faculty family physicians scored higher for continuity of care when compared with general doctors and residents. General doctors had lower GPAQ scores for communication skills and enablement when compared to faculty family physicians and residents. Faculty family physicians had the highest GPAQ scores in many dimensions of family practice skills, followed by residents and general doctors.

Reliability and validity of a Thai version of the General Practice Assessment Questionnaire (GPAQ).

BACKGROUND: The Assessment Questionnaire (GPAQ) is a questionnaire for patients to evaluate primary care in a number of key areas ranging from the access to care, the helpfulness of receptionists, the continuity of care, the doctors'communication skills, the patient's knowledge of self the General Practice care plans after consultation, and overall satisfaction. All questions can be calculated as a GPAQ score allowing services to be analysed, developed, and improved. OBJECTIVE: The General Practice Assessment Questionnaire (GPAQ) was developed in the United Kingdom to evaluate the quality of general practice (i.e. primary care or family medicine). The aim of the present study was to translate and validate a Thai language version of GPAQ. MATERIAL AND METHOD: Cross-sectional study: the content validity was examined by three experts in the Family Medicine field, and then the original GPAQ was translated into Thai with permission from the National Primary Care Research and Development Centre, University of Manchester and Safran. The translation process followed the guidelines for cross-cultural adaptation of self-report measures, including forward translation, synthesis of the translation, back translation, cross-cultural adaptation and pre-testing. The pilot study was done by distributing the questionnaire to a sample of 30 people before revision of the questionnaire. The reliability and validity of the translated version was then examined by distributing the questionnaire to 2,600 people visiting the out-patient clinic at the Department of Family Medicine, Ramathibodi Hospital in October, 2005. RESULTS: The response rate is about 70 percent. The results of the present study showed that the Thai version of GPAQ achieved good levels of reliability and validity, with the range of Cronbach's alpha coefficients being 0.7293-0.8324 in each aspect of GPAQ, namely access, doctor's communication skills, and patient enablement (understanding of self care after the consultation). However, a question about telephone consultations had to be excluded from the questionnaire to reach Cronbach's alpha coefficient of 0.8221. CONCLUSION: After translation and cross-cultural adaptation the Thai version of GPAQ can be used as a patient-administered instrument to evaluate the quality of primary care in Thailand.