Implementation and evaluation of a rural general practice assessment pathway for possible cardiac chest pain using point-of-care troponin testing: a pilot study.

OBJECTIVES: To assess the feasibility and acceptability, and additionally to preliminarily evaluate, the effectiveness and safety of an accelerated diagnostic chest pain pathway in rural general practice using point-of-care troponin to identify patients at low risk of acute myocardial infarction, avoiding unnecessary patient transfer to hospital and enabling early discharge home. DESIGN: A prospective observational pilot evaluation. SETTING: Twelve rural general (family) practices in the Midlands region of New Zealand. PARTICIPANTS: Patients aged ≥18 years who presented acutely to rural general practice with suspected ischaemic chest pain for whom the doctor intended transfer to hospital for serial troponin measurement. OUTCOME MEASURES: The proportion of patients managed using the low-risk pathway without transfer to hospital and without 30-day major adverse cardiac event (MACE); pathway adherence; rate of 30-day MACE; patient satisfaction with care; and agreement between point-of-care and laboratory measured troponin concentrations. RESULTS: A total of 180 patients were assessed by the pathway. The pathway classified 111 patients (61.7%) as low-risk and all were managed in rural general practice with no 30-day MACE (0%, 95% CI 0.0% to 3.3%). Adherence to the low-risk pathway was 95.5% (106 out of 111). Of the 56 patients classified as non-low-risk and referred to hospital, 9 (16.1%) had a 30-day MACE. A further 13 non-low-risk patients were not transferred to hospital, with no events. The sensitivity of the pathway for 30-day MACE was 100.0% (95% CI 70.1% to 100%). Of low-risk patients, 94% reported good to excellent satisfaction with care. Good concordance was observed between point-of-care and duplicate laboratory measured troponin concentrations. CONCLUSIONS: The use of an accelerated diagnostic chest pain pathway incorporating point-of-care troponin in a rural general practice setting was feasible and acceptable, with preliminary results suggesting that it may safely and effectively reduce the urgent transfer of low-risk patients to hospital.

The Rural Family Medicine Café Project: A Social Media Strategy to Reduce Occupational Isolation and Improve Support for Rural Healthcare Professionals.

Background: Globally rural medicine is currently suffering from staff shortages. Social and professional isolation are identified as significant pressures on health professionals working in rural areas. Social media (SOME) has created new methods of social engagement where conventional forms have failed. The Rural Family Medicine Café (RFMC) is a SOME project created to engage and support those interested in rural family medicine thus decreasing occupational isolation. Methods: A quantitative analysis of SOME activity associated with the RFMC was done by measuring the frequency of #ruralcafe, #ruralwomenGP, #ruralGP, #ruralstories, and #ruralmedicine from October 2015 to October 2016 along with the number of Facebook page likes and YouTube views. A time series and regression analysis were done to assess the correlation between the frequencies of hashtag use and the number of new likes or views. A qualitative analysis of the content of tweets using the associated hashtags and comments on the RFMC YouTube videos was then done to assess participants' response to the RFMC. To add context to the data collected, regularly attending participants were invited for a semi-structured interview. Results: There was a positive trend in the number of Facebook page likes (+273%) and Twitter hashtag use (+2,458%) but a negative trend (-92%) in the number of RFMC YouTube views. There was no statistically significant relationship between the number of views on the RFMC YouTube and RFMC associated SOME activity (p = 0.141). A significant relationship was shown between the number of Facebook page likes and the number of views on the RFMC YouTube (p = 0.037). Participants felt positively about the RFMC with recurring themes of; promotion, advocacy, public health, engagement, inspire, sharing, spreading information, feeling connected and general positive comments such as "enjoying tweets," "great discussion." Participants shared anecdotes, useful links, and book recommendations. Conclusion: The RFMC has seen an increase in the amount of associated SOME activity despite having less viewers. This is most likely due to the few participants of the RFMC continuing the café discussions on SOME, particularly Twitter, and engaging outside of the RFMC. The RFMC has developed into a virtual community which is reducing occupational isolation for its participants.

Demographic, Health Care, and Fertility-related Characteristics of Adults Aged 18-44 Who Have Ever Been in Foster Care: United States, 2011-2017.

Objective-This report presents demographic characteristics, health service access and use, and timing of key fertility-related milestones among adults aged 18-44 who had ever been in foster care as compared with those who had never been in foster care in the United States. Methods-The National Survey of Family Growth (NSFG) is a nationally representative survey, with data collected through in-person interviews of the household population of the United States. Analyses used 6 years of NSFG interviews spanning September 2011 through September 2017, and included 11,527 male and 14,439 female respondents aged 18-44. Bivariate analyses examined demographic characteristics and health service access and use by having ever been in foster care, as measured by household roster information and childhood background items. Cumulative probabilities of first sexual intercourse, first marriage, and first birth by age were estimated using Kaplan-Meier procedures. All estimates were stratified by sex. Results-Overall, 2.6% of adults aged 18-44 had ever been in foster care, and the percentage was higher for women (3.0%) than for men (2.3%). Lower percentages of men and women who were ever in foster care had a bachelor's degree or higher (4.8% for men and 9.1% for women) compared with those who had never been in foster care (31.1% and 36.2%, respectively). Receipt of public assistance in the past 12 months was more likely among adults who were ever in foster care compared with those who were never in foster care. Adults ever in foster care were less likely than adults never in foster care to be currently covered by private health insurance and were more likely to be covered by Medicaid. Adults ever in foster care also had higher probabilities of first sexual intercourse and first births at younger ages than those never in foster care.

Fetal Alcohol Spectrum Disorders in a Rocky Mountain Region City: Child Characteristics, Maternal Risk Traits, and Prevalence.

OBJECTIVE: To document prevalence and traits of children with fetal alcohol spectrum disorders (FASD) and maternal risk factors in a Rocky Mountain city. METHODS: Variations on active case ascertainment methods were used in 2 first-grade cohorts in all city schools. The consent rate was 59.2%. Children were assessed for physical growth, dysmorphology, and neurobehavior and their mothers interviewed. RESULTS: Thirty-eight children were diagnosed with FASD and compared with 278 typically developing controls. Total dysmorphology scores summarized well the key physical indicators of FASD and defined specific diagnostic groups. On average, children with FASD performed significantly poorer than controls on intellectual, adaptive, learning, attention, and behavioral tasks. More mothers of children with FASD reported drinking prior to pregnancy and in the first and second trimesters, and had partners with drinking problems than mothers of controls; however, reports of comorbid alcohol use and 6 other drugs were similar for mothers of children with FASD and mothers of controls. Mothers of children with FASD were significantly younger at pregnancy, had lower average weight before pregnancy and less education, initiated prenatal clinic visits later, and reported more health problems (e.g., stomach ulcers and accidents). Children with FASD had significantly lower birth weight and more problems at birth, and were less likely to be living with biological mother and father. Controlling for other drug and tobacco use, a FASD diagnosis is 6.7 times (OR = 6.720, 95% CI = 1.6 to 28.0) more likely among children of women reporting prepregnancy drinking of 3 drinks per drinking day (DDD) and 7.6 times (OR = 7.590, 95% CI = 2.0 to 31.5) more likely at 5 DDD. Prevalence of FAS was 2.9-5.8 per 1,000 children, and total FASD was 34.9 to 82.5 per 1,000 children or 3.5 to 8.3% at this site. CONCLUSION: This site had the second highest prevalence of FASD of the 4 Collaboration on FASD Prevalence sites and clearly identifiable child and maternal risk traits.

"I don't want to take any risks even if it's gonna mean this service-user is gonna be happier": A thematic analysis of community support staff perspectives on delivering Transforming Care.

BACKGROUND: Transforming Care is making mixed progress in supporting people with intellectual and developmental disabilities, and complex needs, move to more appropriate specialist accommodations closer to home. Community support staff often spend greatest amounts of time with service-users, yet are some of the least heard voices about why placements succeed and fail to varying extents. METHOD: Managers and support staff (n = 13), working in ostensibly "specialist" community placements, were interviewed about perceived barriers and facilitators to implementing Transforming Care. Transcripts were subjected to thematic analysis. RESULTS: Participants identified difficulties balancing people's rights, safety and quality of life needs, and felt the system's expectations of them are hard to deliver within the resources, legislation, values and support models provided them. Multidisciplinary expertise was highly valued for both emotional and practical support, but was least valued when perceived as overly blaming or inspectorial. Specialist health input was seen to withdraw prematurely for this particular client group. CONCLUSION: Recommendations are provided for how staff perspectives should inform Transforming Care in interests of service-users.

BIRTH OF A MIDWIFE.

Like many experienced midwives and nurses I have a plethora of experience spanning over 13 years. I completed my nursing degree in my home town of Derry City, Northern Ireland before completing my Post Graduate Degree in Midwifery at Queens University, Belfast.

A preliminary investigation to explore the cognitive resources of physicians experiencing difficulty in training.

BACKGROUND: Treating patients is complex, and research shows that there are differences in cognitive resources between physicians who experience difficulties, and those who do not. It is possible that differences in some cognitive resources could explain the difficulties faced by some physicians. In this study, we explore differences in cognitive resources between different groups of physicians (that is, between native (UK) physicians and International Medical Graduates (IMG); those who continue with training versus those who were subsequently removed from the training programme); and also between physicians experiencing difficulties compared with the general population. METHODS: A secondary evaluation was conducted on an anonymised dataset provided by the East Midlands Professional Support Unit (PSU). One hundred and twenty one postgraduate trainee physicians took part in an Educational Psychology assessment through PSU. Referrals to the PSU were mainly on the basis of problems with exam progression and difficulties in communication skills, organisation and confidence. Cognitive resources were assessed using the Wechsler Adult Intelligence Scale (WAIS-IV). Physicians were categorised into three PSU outcomes: 'Continued in training', 'Removed from training' and 'Active' (currently accessing the PSU). RESULTS: Using a one-sample Z test, we compared the referred physician sample to a UK general population sample on the WAIS-IV and found the referred sample significantly higher in Verbal Comprehension (VCI; z = 8.78) and significantly lower in Working Memory (WMI; z = -4.59). In addition, the native sample were significantly higher in Verbal Comprehension than the UK general population sample (VCI; native physicians: z = 9.95, p < .001, d = 1.25), whilst there was a lesser effect for the difference between the IMG sample and the UK general population (z = 2.13, p = .03, d = 0.29). Findings also showed a significant difference in VCI scores between those physicians who were 'Removed from training' and those who 'Continued in training'. CONCLUSIONS: Our results suggest it is important to understand the cognitive resources of physicians to provide a more focussed explanation of those who experience difficulties in training. This will help to implement more targeted interventions to help physicians develop compensatory strategies.

A role for virtue in unifying the 'knowledge' and 'caring' discourses in nursing theory.

A critical examination of contemporary nursing theory suggests that two distinct discourses coexist within this field. On the one hand, proponents of the 'knowledge discourse' argue that nurses should drop the 'virtue script' and focus on the scientific and technical aspects of their work. On the other hand, proponents of the 'caring discourse' promote a view of nursing that embodies humanistic qualities such as compassion, empathy and mutuality. In view of this, we suggest a way to reconcile both discourses despite the fact that they appear to be at odds theoretically and practically. To that end, we argue that nursing theory must give a prominent role to the Aristotelian conception of virtue, and we offer an account that includes both character and intellectual virtues. This account allows for a focus on moral competence but also accommodates the demands for discipline-specific knowledge. Our account incorporates the caring discourse by suggesting a way for individuals to cultivate the conditions within themselves that make 'caring in nursing' possible, while the knowledge discourse is accommodated via the acquisition of the intellectual virtues. The process for achieving both these ends is the same: an intention to consistently develop, hone and exercise certain character traits over time.

Demystifying professional support for trainees: what does it mean?

'Professional support' is a commonly used term in medical training but it is not always clear what is meant by it and what the implications are for an individual trainee and his/her trainer. This article explores the concept of professional support in medical training.

Current Contraceptive Use and Variation by Selected Characteristics Among Women Aged 15-44: United States, 2011-2013.

OBJECTIVE: This report describes current contraceptive use among women of childbearing age (ages 15-44) during 2011-2013. Current contraceptive use is defined as use during the month of interview, not for a specific act of sexual intercourse. This report's primary focus is describing patterns of contraceptive use among women who are currently using contraception, by social and demographic characteristics. Data from 2002 and 2006-2010 are presented for comparison. METHODS-Data for the 2011-2013 National Survey of Family Growth (NSFG) were collected through in-person interviews in respondents' homes. The 2011-2013 NSFG, a nationally representative survey conducted by the Centers for Disease Control and Prevention's National Center for Health· Statistics, was based on interviews with 10,416 women and men aged 15-44 in the U.S. household population. This report is based on the sample of 5,601 women interviewed in 2011-2013, with a response rate of 73.4%. RESULTS-Among women currently using contraception, the most commonly used methods were the pill (25.9%, or 9.7 million women), female sterilization (25.1 %, or 9.4 million women), the male condom (15.3%, or 5.8 million women), and long-acting reversible contraception (LARC)-intrauterine devices or contraceptive implants (11.6%, or 4.4 million women). Differences in method use were seen across social and demographic characteristics. Comparisons between time points reveal some differences, such as higher use of LARC in 2011-2013 compared with earlier time points.

Nonuse of contraception among women at risk of unintended pregnancy in the United States.

OBJECTIVE: This paper seeks to determine factors associated with nonuse of contraception by women at risk of unintended pregnancy in the United States. This nonuse may be associated with about 900,000 unintended births in the US each year. STUDY DESIGN: The 2002 and 2006-2010 National Surveys of Family Growth were combined to yield a nationally representative sample of 9,445 women at risk of unintended pregnancy. Logistic regression analyses identified factors associated with nonuse of contraception. RESULTS: This analysis reveals previously undocumented patterns of nonuse: controlling for confounding variables, cohabiting women [adjusted odds ratio (AOR)=2.3, 95% confidence interval (CI)=1.45-3.52] had higher odds of nonuse than married women; women who reported a difficulty getting pregnant (AOR=2.5, 95% CI=2.01-3.01) had higher odds of nonuse than those who did not. Nonuse was also more common among women with a master's degree or more (AOR=1.5, 95% CI=1.11-2.08) compared with those with some college or bachelor's degree, and it was more common among women in their first year after first intercourse than after the first year (AOR 1.6, 95% CI=1.12-2.22). Among women who had a recent unintended birth, the most common reason for not using contraception prior to conception was that she did not think she could get pregnant. CONCLUSIONS: This study establishes national estimates of reasons for nonuse of contraception and identifies some new subgroups at risk of nonuse. IMPLICATIONS: These results may help better understand factors affecting nonuse of contraception and develop strategies for preventing unintended pregnancy in the United States.

Trends in long-acting reversible contraception use among U.S. women aged 15-44.

Long-acting reversible contraceptives (LARCs), which include intrauterine devices (IUDs) and subdermal hormonal implants, are gaining popularity due to their high efficacy in preventing unintended pregnancies. IUD use was more common among U.S. women in the 1970s before concerns over safety led to a decline in use (1); however, since approval of a 5-year contraceptive implant in 1990 and redesigned IUDs, there has been growing interest in the use of LARCs for unintended pregnancy prevention. Using data from the 1982, 1988, 1995, 2002, 2006­2010, and 2011­2013 National Survey of Family Growth (NSFG), this report examines trends in current LARC use among women aged 15­44 and describes patterns of use by age, race and Hispanic origin, and parity.

Current contraceptive status among women aged 15-44: United States, 2011-2013.

Nearly all women use contraception at some point in their lifetimes, although at any given time they may not be using contraception for reasons such as seeking pregnancy, being pregnant, or not being sexually active. Using data from the 2011-2013 National Survey of Family Growth (NSFG) on contraceptive use in the month of the interview, this report provides a snapshot of current contraceptive status among women aged 15-44 in the United States. In addition to describing use of any method by age, Hispanic origin and race, and educational attainment, patterns of use are described for the four most commonly used contraceptive methods: the oral contraceptive pill, female sterilization, the male condom, and long-acting reversible contraceptives, which include contraceptive implants and intrauterine devices.

Declaração de Gramado pela Saúde Rural nos países em desenvolvimento / Gramado Statement for Rural Health in developing countries / Declaración de Gramado para la Salud Rural en los países en desarrollo

Nós, aqui reunidos na XII Conferência Mundial de Saúde Rural da Wonca / IV Congresso Sulbrasileiro de Medicina de Família e Comunidade, declaramos como reflexão e recomendação para a saúde das populações rurais, em particular para os países em desenvolvimento, o que segue. Sistemas de saúde para uma melhor saúde rural A saúde rural não pode ser pensada separadamente do desenvolvimento do sistema de saúde. Pessoas de países em desenvolvimento merecem um uso racional e eficiente dos recursos disponíveis para gastos de saúde a fim de se otimizarem os resultados e a satisfação com os serviços. O aprimoramento da saúde rural deve estar associado a uma forte orientação do sistema de saúde para atenção primária à saúde1 e orientação para as reais necessidades das comunidades. Cobertura de saúde universal com equidade nos sistemas de saúde deve ser uma prioridade global2,3 Longitudinalidade e atenção integral devem ser constantemente alvo das políticas de saúde. Cuidado centrado na comunidade com competência cultural deve ser o princípio de todas as políticas de sistema de saúde. Hospitais e unidades de saúde rurais devem estar adequadamente vinculados a uma rede de saúde constantemente avaliada, e esta rede vinculada aos serviços mais especializados por meio de fluxos estabelecidos de comunicação, regulação e transporte. Envolvimento com a comunidade em todos os níveis das decisões deve ser encorajado para todos os sistemas de saúde. "Rural Proofing" implica "pensar no rural", consultar as comunidades rurais com a revisão de evidências rurais, desenvolver soluções rurais que são postas em prática, assim como monitorar, reavaliando continuamente e agindo em resposta a um ambiente em mudança.4 "Rural Proofing" deve ser centrado na pessoa e derivado por meio da lente do conhecimento contextualizado rural. É declaração do Wonca Working Party on Rural Practice (WWPRP) que Rural Proofing deve ser um aspecto rotineiro da aprovação e implementação das políticas. O WWPRP vai procurar desenvolver uma abordagem para ferramentas de Rural Proofing que abranja os princípios de melhoria da saúde para todas as pessoas rurais com uma apresentação do progresso dos resultados em 2015, na 13a Conferência Mundial de Saúde Rural da WONCA. Estratégias para o desenvolvimento profissional contínuo devem envolver tecnologias de suporte remoto e formação. As iniciativas de sucesso de treinamento em serviços de medicina de família já existentes devem ser exploradas. Competências desejáveis para a prática rural devem ser definidas e adicionadas de forma adaptada às diferentes realidades locais e necessidades. Devem-se qualificar e corresponsabilizar os gestores de saúde para a adoção de políticas orientadas pelo uso culturalmente apropriado das melhores evidências disponíveis. A necessidade de discussão das particularidades da saúde rural e da prática profissional é essencial. No entanto, a busca excessiva de definições muito estritas pode não ser útil para a implementação de políticas que realmente impactem a saúde dessas populações.5 Categorias intermediárias geradas pelo conceito de rururbano6,7 são fundamentais para estimular o intercâmbio de conhecimentos de medicina rural diante da enorme complexidade das situações sociais contemporâneas. Entende-se aqui rururbano como "um processo de desenvolvimento socioeconômico que combina, em termos de forma e conteúdo, uma única vivência regional e nacional. Ela representa uma rejeição à absoluta urbanização e, ao mesmo tempo, à idealização de camponeses vivendo arcaicamente em espaço rurais."6 O conceito também é utilizado para discutir a complexidade da definição de rural/urbano na legislação brasileira por outros autores, ao constatar-se que quase 15% da população nacional não se encaixam claramente em nenhuma das categorias isoladamente.7 O estabelecimento de um sistema de saúde, o que especificamente inclui a preocupação com a saúde das populações rurais, implica estabelecer redes de cooperação eficazes entre comunidades, educação e instituições de pesquisa, serviços de saúde e de gestão. Reconhecemos o trabalho realizado anteriormente nos fóruns rurais de Cartagena, Santa Fé e Montevidéu como importantes para o desenvolvimento da saúde rural na América Latina. Recursos humanos para a Saúde Rural A má distribuição e escassez de recursos humanos são muitas vezes maiores e mais graves nos países em desenvolvimento, e as soluções para este problema devem ser idealmente trabalhadas de forma conjunta por políticas de retenção e de qualidade, respeitando-se as recomendações internacionais8 e acordos para a migração internacional ética.9,10 O melhor perfil a ser alcançado por meio de políticas de alta prioridade para otimizar a saúde rural é o de pós-graduado em medicina de família. Em países em desenvolvimento, muitas vezes serão exigidos tempo e recursos para estimular a formação deste perfil, mas no médio e longo prazo, isto é custo-efetivo.1 Programas de residência devem ser a estratégia de padrão-ouro para este objetivo. Condições devem ser criadas para aumentar o número de vagas, sua descentralização e a garantia de uma quantidade adequada de bolsas de estudos para que os profissionais de saúde não sejam desviados para outras áreas nem entrem diretamente no mercado de trabalho. Outras maneiras de alcançar mais rapidamente o número necessário de profissionais devem preservar as diferenças entre esses modelos e valorar diferentemente profissionais com uma formação mais completa. Um escopo mais amplo de habilidades e conhecimentos deve ser incluído em uma formação estendida para esses profissionais. Em locais onde já há programas de medicina de família, períodos adicionais com conteúdo rural devem ser criados, ou seja, com conteúdos especiais ligados à realidade local, podendo incluir cirurgia, habilidades e conhecimentos de obstetrícia, atendimento de emergência, pediatria, etc. Políticas de migração, serviços obrigatórios, recrutamentos temporários sem estratégias de retenção devem ser estratégias excepcionais e não devem ser as principais políticas de nenhum país. Descentralização rural da formação, políticas para estimular os alunos advindos de áreas rurais, melhoramentos na qualidade do trabalho, de vida e de pagamento, incluindo programas de carreira profissional devem ser parte de políticas multifatoriais para retenção. Migração de profissionais internacionais deve sempre respeitar as legislações nacionais e as recomendações internacionais. Trabalhadores de saúde rural que vivem e trabalham em zonas rurais devem ser valorizados e sua situação sempre deve ser comparada com as novas políticas para evitar prejuízo destes. A exposição dos alunos de todas profissões da área da saúde deve incluir todos os possíveis cenários de prática profissional, incluindo rural e rururbanas, e deve ser planejada longitudinalmente sempre que possível. A formação necessariamente deve ser direcionada para as necessidades locais. As competências (conhecimentos, habilidades e atitudes) de medicina de família rural devem ser parte da formação de graduação. Unidades de cuidados de ensino nas áreas rurais são o cenário adequado para a formação de saúde rural e capacitação.

Use of emergency contraception among women aged 15-44: United States, 2006-2010.

Emergency contraception can be used by women after sexual intercourse in an effort to prevent an unintended pregnancy. Roughly one-half of all pregnancies in the United States are unintended (1,2). The FDA first approved emergency contraceptive pills in 1998, but there is evidence of limited use of hormonal contraceptives for emergency contraception since the 1960s (3,4). Now, there are at least four brands of emergency contraceptive pills; most are available over the counter for women aged 17 and over (5). Although insertion of a copper intrauterine device can be used for emergency contraception (1,4), this report focuses only on emergency contraceptive pills. This report describes trends and variation in the use of emergency contraception and reasons for use among sexually experienced women aged 15-44 using the 2006-2010 National Survey of Family Growth.

Conceptual issues in neurodevelopmental disorders: lives out of synch.

PURPOSE OF REVIEW: Current revision of the two major psychiatric classification systems has elicited particular comment on neurodevelopmental disorders, which have seen increased provision of specialist clinical services, user group activity, fictional and biographical accounts, and research. Philosophical scrutiny of autism research and literature provides an additional perspective. RECENT FINDINGS: Neurodevelopmental disorders show considerable overlap neuropsychologically, physiologically and genetically. They overlap diagnostically with schizophrenia, personality disorders, anxiety and depression. Of the two main diagnostic groups, there is more evidence of change with maturation in autism spectrum disorder than attention-deficit hyperactivity disorder. Interventions should combine cognitive, affective and embodied aspects of these disorders, and encompass the individual and their social environment. There is considerable evidence of the toll that caring for people with neurodevelopmental disorders exerts on parents. SUMMARY: Neurodevelopmental disorders are multifaceted: research addressed to connection rather than further Balkanization is more likely to be fruitful. Clinicians should consider which facets are displayed symptomatically to enable people to grow through rather than surrender to their impairments. Social scaffolding optimizes functional well being. Future research should take into account the tensions in the relationship between research and user groups, and examine the experiences of adults and of the spouses and partners of those affected.