Patients frequently referred from primary care to hospital outpatient clinics for medically 'unexplained' symptoms

BACKGROUND One third of frequent attenders to UK outpatient clinics have symptoms that are inadequately explained by disease according to specialist opinion (medically 'unexplained'). Some of these patients are frequently referred for similar symptoms to multiple specialties. The characteristics and treatment needs ofthese frequently referred patients are poorly understood.AIM The aim was to identify and describe patients frequently referred from primary care to hospital clinics for medically 'unexplained' symptoms (FRMUS) and compare them with patients frequently referred with medically explained symptoms (FRMES) and patients infrequently referred for symptoms (IRS).HYPOTHESES Compared to FRMES and IRS patients, a greater proportion of FRMUS patients would have anxiety or depression and this would be inadequately treated. Subsidiary hypotheses relating to: consulting multiple doctors, health care costs, perceived general health, satisfaction with care, and health beliefs, as well as the general practitioners' (GPs) expressed difficulty managing the patient, were also tested.METHODS The methodology employed for this study involved three phases as follows: (1) Identification of cases and controls from five Edinburgh general practices using a combination ofNational Health Service (NHS) referral data and primary care case notes. (2) A case-control study to describe and compare FRMUS patients with the two control patient groups. This comprised a questionnaire survey of GPs and patients, and a lifetime case note review for a 15% random selection of FRMUS and FRMES participants. (3) An economic analysis of the health care contacts.RESULTS FRMUS patients made up 1.1% (293/26252; CI 0.01-0.013) of the primary care population aged 18-65 years, and nearly two thirds (218/293, 74.4%) were female. The FRMUS patients had statistically more anxiety (67/193, 34.7%) when compared to 37 ofthe 162 FRMES (22.8%, OR 1.8, CI 1.12-2.88) and 23 of the 152 IRS (15.1%, OR 2.98, CI 1.75-5.09) comparison patient groups. Although there was no statistical difference for diagnoses of depression between the FR groups, the FRMUS patients had a significantly greater mean score for depressive symptoms than the FRMES control patients (mean difference 2.03, CI 0.66-3.41). Of the 67 FRMUS patients with an anxiety disorder 41(61.2%) were receiving adequate treatment, and this was considerably more than the six of 37 FRMES (16.2%, OR 8.147, CI 2.99- 22.21) and the six of 23 IRS (26.1%, OR 4.47, CI 1.56-12.8) comparison patients who had an anxiety disorder. Treatment for those patients with depression was also significantly greater for FRMUS patients (43/64, 67.2%) compared with the FRMES (10/41, 24.4%, OR 6.35, CI 2.62-15.36) and IRS (5/21, 23.8%, OR 6.56, CI 2.11- 20.32) groups. FRMUS patients were also more likely to: be female, reside in a deprived area of Lothian, referred by multiple doctors, have problems considered to be more difficult to help by a GP, have high health care costs, and report poor general physical and mental health.DISCUSSION A third of FRMUS patients had anxiety and depression, the majority of whom were receiving 'adequate treatment'. Factors other than undetected anxiety and depression may better explain why these patients are repeatedly referred to outpatient clinics for 'unexplained' symptoms

Health promotion in schools: a multi-method evaluation of an Australian School Youth Health Nurse Program

BACKGROUND: Health promotion provides a key opportunity to empower young people to make informed choices regarding key health-related behaviours such as tobacco and alcohol use, sexual practices, dietary choices and physical activity. This paper describes the evaluation of a pilot School Youth Health Nurse (SYHN) Program, which aims to integrate a Registered Nurse into school communities to deliver health promotion through group education and individual sessions. METHODS: The evaluation was guided by the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework. The objectives were to explore: 1) whether the Program was accessible to the high school students; 2) the impacts of the Program on key stakeholders; 3) which factors affected adoption of the Program; 4) whether implementation was consistent with the Program intent; and 5) the long-term sustainability of the Program. Research included retrospective analysis of Program records, administration of a survey of student experiences and interviews with 38 stakeholders. RESULTS: This evaluation provided evidence that the SYHN Program is reaching students in need, is effective, has been adopted successfully in schools, is being implemented as intended and could be maintained with sustained funding. The nurses deliver an accessible and acceptable primary health care service, focused on health promotion, prevention and early intervention. After some initial uncertainty about the scope and nature of the role, the nurses are a respected source of health information in the schools, consulted on curriculum development and contributing to whole-of-school health activities. CONCLUSIONS: Findings demonstrate that the SYHN model is feasible and acceptable to the students and schools involved in the pilot. The Program provides health promotion and accessible primary health care in the school setting, consistent with the Health Promoting Schools framework.This project was supported by funding from the Australian Capital Territory Government Health Directorate, Health Promotion Branch

Mother’s little helper? Contrasting accounts of benzodiazepine and methadone use among drug-dependent parents in the UK.

Aims: To explore the ways in which opioid-dependent parents accounted for their use of opioids and benzodiazepines during and after pregnancy. Methods: Longitudinal qualitative interviews [n?=?45] with 19 opioid-dependent adults recruited in Scotland, UK, were held during the antenatal and post-natal period. Interviews focused on parenting and parenting support within the context of problem drug use and were analysed using a narrative informed, thematic analysis. Findings: The majority of participants described using benzodiazepines in addition to opioids. Almost all indicated a desire to stop or reduce opioid use, whereas cessation or reduction of benzodiazepines was rarely prioritised. In stark contrast to opioid dependence, benzodiazepine dependence was portrayed as unproblematic, therapeutic and acceptable in the context of family life. Whereas opioid dependence was framed as stigmatising, benzodiazepine use and dependence was normalised. An exception was benzodiazepine use by men which was occasionally associated with aggression and domestic abuse. Conclusions: Drug-dependent parents attach different meanings to opioid and benzodiazepine use and dependence in the context of parenthood. Divergent meanings, and stigma, may impact on stated commitment to stability or recovery from dependent drug-use. Attention should be paid to the way in which policy and practice regarding OST and benzodiazepines reflects this divergenc

The interpretation of low mood and worry by high users of secondary care with medically unexplained symptoms

DA - 20111021 IS - 1471-2296 (Electronic) IS - 1471-2296 (Linking) LA - eng PT - Journal Article SB - IMPeer reviewedPublisher PD

Substance, structure and stigma: Parents in the UK accounting for opioid substitution therapy during the antenatal and postnatal periods.

BackgroundParenting and pregnancy in the context of drug use is a contentious topic, high on the policy agenda. Providing effective support to parents who are opioid dependent, through early intervention, access to drug treatment and parenting skills training, is a priority. However, little is known about opioid dependent parents’ experiences and understanding of parenting support during the antenatal and postnatal periods. This paper focuses on the position and impact of opioid substitution therapy (OST) in the accounts of parents who were expecting, or who had recently had, a baby in the UK.MethodsSemi-structured qualitative interviews were held with a purposive sample of 19 opioid dependent service users (14 female, 5 male). Longitudinal data was collected across the antenatal and postnatal (up to 1 year) periods, with participants interviewed up to three times. Forty-five interviews were analysed thematically, using a constant comparison method, underpinned by a sociologically informed narrative approach.ResultsParticipants’ accounts of drug treatment were clearly oriented towards demonstrating that they were doing ‘the best thing’ for their baby. For some, OST was framed as a route to what was seen as a ‘normal’ family life; for others, OST was a barrier to such normality. Challenges related to: the physiological effects of opioid dependence; structural constraints associated with treatment regimes; and the impact of negative societal views about drug-using parents.ConclusionParents’ accounts of OST can be seen as a response to socio-cultural ideals of a ‘good’, drug-free parent. Reflecting the liminal position parents engaged in OST found themselves in, their narratives entailed reconciling their status as a ‘drug-using parent’ with a view of an ‘ideal parent’ who was abstinent

The burden of care: a focus group study of healthcare practitioners in Scotland talking about parental drug misuse

Parenting and family support are key prevention and intervention strategies for improving outcomes for children and families affected by parental drug misuse. However, little is known about the delivery of parenting support for drug-dependent parents, particularly within universal healthcare services. This study aimed to explore the way healthcare practitioners engage with this challenging agenda. Four multidisciplinary focus groups involving a purposive sample of 18 experienced healthcare professionals were conducted in Scotland. Participants included general practitioners, midwives, public health nurses and addiction staff who work together to provide care for vulnerable families. A focus group topic guide was developed to explore the views and experiences of these healthcare professionals in relation to providing parenting support for drug-using parents, predominantly those receiving opioid substitution therapy. Data were analysed using a constant comparison method and thematic approach. The overarching narrative which united the focus group discussions was about the ‘burden of care’ that these families pose for frontline healthcare professionals. Recurring themes centred on three key issues: the problematic nature of drug-using parents themselves; clinical challenges in living up to the ideals of professional practice; and the wider context in which current practice is governed. Professionals expressed ambivalence over their parenting support role; anxiety over responsibility for intervening with this ‘hard-to-engage’ population; and concern over ‘dwindling’ resources and lack of organisational support. Nevertheless, strategies and opportunities for providing parenting support were acknowledged and there was consensus about the need for further skills training. Despite a proliferation of policy and good practice guidance on the delivery of parenting support for drug-dependent parents, the findings of this study suggest that significant challenges remain. Notably, our findings raise questions about whose role it is to provide parenting support to drug-using mothers and fathers, especially those who are not involved in the child protection system

A surge in serum mucosal cytokines associated with seroconversion in children at risk for type 1 diabetes

ABSTRACT Aims/Introduction Autoantibodies to pancreatic islet antigens identify young children at high risk of type 1 diabetes. On a background of genetic susceptibility, islet autoimmunity is thought to be driven by environmental factors, of which enteric viruses are prime candidates. We sought evidence for enteric pathology in children genetically at‐risk for type 1 diabetes followed from birth who had developed islet autoantibodies (“seroconverted”), by measuring mucosa‐associated cytokines in their sera. Materials and Methods Sera were collected 3 monthly from birth from children with a first‐degree type 1 diabetes relative, in the Environmental Determinants of Islet Autoimmunity (ENDIA) study. Children who seroconverted were matched for sex, age, and sample availability with seronegative children. Luminex xMap technology was used to measure serum cytokines. Results Of eight children who seroconverted, for whom serum samples were available at least 6 months before and after seroconversion, the serum concentrations of mucosa‐associated cytokines IL‐21, IL‐22, IL‐25, and IL‐10, the Th17‐related cytokines IL‐17F and IL‐23, as well as IL‐33, IFN‐γ, and IL‐4, peaked from a low baseline in seven around the time of seroconversion and in one preceding seroconversion. These changes were not detected in eight sex‐ and age‐matched seronegative controls, or in a separate cohort of 11 unmatched seronegative children. Conclusions In a cohort of children at risk for type 1 diabetes followed from birth, a transient, systemic increase in mucosa‐associated cytokines around the time of seroconversion lends support to the view that mucosal infection, e.g., by an enteric virus, may drive the development of islet autoimmunity

Changes in pancreatic exocrine function in young at-risk children followed to islet autoimmunity and type 1 diabetes in the ENDIA study

Backgrounds: We aimed to monitor pancreatic exocrine function longitudinally in relation to the development of islet autoimmunity (IA) and type 1 diabetes (T1D) in at-risk children with a first-degree relative with T1D, who were followed prospectively in the Environmental Determinants of Islet Autoimmunity (ENDIA) study. Methods: Fecal elastase-1 (FE-1) concentration was measured longitudinally in 85 ENDIA children from median age 1.0 (IQR 0.7,1.3) year. Twenty-eight of 85 children (progressors) developed persistent islet autoantibodies at median age of 1.5 (IQR 1.1,2.5) years, of whom 11 went on to develop clinical diabetes. The other 57 islet autoantibody-negative children (non-progressors) followed similarly were age and gender-matched with the progressors. An adjusted linear mixed model compared FE-1 concentrations in progressors and non-progressors. Results: Baseline FE-1 did not differ between progressors and non-progressors, or by HLA DR type or proband status. FE-1 decreased over time in progressors in comparison to non-progressors (Wald statistic 5.46, P =.02); in some progressors the fall in FE-1 preceded the onset of IA. Conclusions: Pancreatic exocrine function decreases in the majority of young at-risk children who progress to IA and T1D