Perceptions of labour pain management of Dutch primary care midwives : a focus group study

Background: Labour pain is a major concern for women, their partners and maternity health care professionals. However, little is known about Dutch midwives' perceptions of working with women experiencing labour pain. The aim of this study was to explore midwives' perceptions of supporting women in dealing with pain during labour. Methods: We conducted a qualitative focus group study with four focus groups, including a total of 23 midwives from 23 midwifery practices across the country. Purposive sampling was used to select the practices. The constant comparison method of Glaser and Straus (1967, ren. 1995) was used to gain an understanding of midwives' perceptions regarding labour pain management. Results: We found two main themes. The first theme concerned the midwives' experienced professional role conflict, which was reflected in their approach of labour pain management along a spectrum from "working with pain" to a "pain relief" approach. The second theme identified situational factors, including time constraints; discontinuity of care; role of the partner; and various cultural influences, that altered the context in which care was provided and how midwives saw their professional role. Conclusion: Midwives felt challenged by the need to balance their professional attitude towards normal birth and labour pain, which favours working with pain, with the shift in society towards a wider acceptance of pharmacological pain management during labour. This shift compelled them to redefine their professional identity

How GPs value guidelines applied to patients with multimorbidity: A qualitative study

Objectives: To explore and describe the value general practitioner (GPs) attribute to medical guidelines when they are applied to patients with multimorbidity, and to describe which benefits GPs experience from guideline adherence in these patients. Also, we aimed to identify limitations from guideline adherence in patients with multimorbidity, as perceived by GPs, and to describe their empirical solutions to manage these obstacles. Design: Focus group study with purposive sampling of participants. Focus groups were guided by an experienced moderator who used an interview guide. Interviews were transcribed verbatim. Data analysis was performed by two researchers using the constant comparison analysis technique and field notes were used in the analysis. Data collection proceeded until saturation was reached. Setting: Primary care, eastern part of The Netherlands. Participants: Dutch GPs, heterogeneous in age, sex and academic involvement. Results: 25 GPs participated in five focus groups. GPs valued the guidance that guidelines provide, but experienced shortcomings when they were applied to patients with multimorbidity. Taking these patients’ personal circumstances into account was regarded as important, but it was impeded by a consistent focus on guideline adherence. Preventative measures were considered less appropriate in (elderly) patients with multimorbidity. Moreover, the applicability of guidelines in patients with multimorbidity was questioned. GPs’ extensive practical experience with managing multimorbidity resulted in several empirical solutions, for example, using their ‘common sense’ to respond to the perceived shortcomings. Conclusions: GPs applying guidelines for patients with multimorbidity integrate patient-specific factors in their medical decisions, aiming for patient-centred solutions. Such integration of clinical experience and best evidence is required to practise evidence-based medicine. More flexibility in pay-for-performance systems is needed to facilitate this integration. Several improvements in guideline reporting are necessary to enhance the applicability of guidelines in patients with multimorbidity

Дифференциальная диагностика дисфункции и воспаления желчевыводящей системы у детей

ЖЕЛЧНЫХ ПУТЕЙ БОЛЕЗНИ /ДИАГНХОЛЕЦИСТИТДЕТЕЙ ОХРАНЫ ЗДОРОВЬЯ СЛУЖБ

Exploring the impact of chronic obstructive pulmonary disease (COPD) on diabetes control in diabetes patients: a prospective observational study in general practice

Background:Little is known about the association between COPD and diabetes control parameters.Aims:To explore the association between comorbid COPD and longitudinal glycaemic control (HbA 1C) and systolic blood pressure (SBP) in a primary care cohort of diabetes patients.Methods:This is a prospective cohort study of type 2 diabetes patients in the Netherlands. In a mixed model analysis, we tested differences in the 5-year longitudinal development of HbA 1C and SBP according to COPD comorbidity (present/absent). We corrected for relevant covariates. In subgroup effect analyses, we tested whether potential differences between diabetes patients with/without COPD were modified by age, sex, socio-economic status (SES) and body mass index (BMI).Results:We analysed 610 diabetes patients. A total of 63 patients (10.3%) had comorbid COPD. The presence of COPD was not significantly associated with the longitudinal development of HbA 1C (P=0.54) or SBP (P=0.33), but subgroup effect analyses showed significant effect modification by SES (P<0.01) and BMI (P=0.03) on SBP. Diabetes patients without COPD had a flat SBP trend over time, with higher values in patients with a high BMI. For diabetes patients with COPD, SBP gradually increased over time in the middle-And high-SES groups, and it decreased over time in those in the low-SES group.Conclusions:The longitudinal development of HbA 1C was not significantly associated with comorbid COPD in diabetes patients. The course of SBP in diabetes patients with COPD is significantly associated with SES (not BMI) in contrast to those without COPD. Comorbid COPD was associated with longitudinal diabetes control parameters, but it has complex interactions with other patient characteristics. Further research is needed

The effect of comorbidity on glycemic control and systolic blood pressure in type 2 diabetes: A cohort study with 5 year follow-up in primary care

To explore the longitudinal effect of chronic comorbid diseases on glycemic control (HbA1C) and systolic blood pressure (SBP) in type 2 diabetes patients. Methods In a representative primary care cohort of patients with newly diagnosed type 2 diabetes in The Netherlands (n = 610), we tested differences in the five year trend of HbA1C and SBP according to comorbidity profiles. In a mixed model analysis technique we corrected for relevant covariates. Influence of comorbidity (a chronic disease already present when diabetes was diagnosed) was tested as total number of comorbid diseases, and as presence of specific disease groups, i.e. cardiovascular, mental, and musculoskeletal disease, malignancies, and COPD. In subgroup effect analyses we tested if potential differences were modified by age, sex, socioeconomic status, and BMI. Results The number of comorbid diseases significantly influenced the SBP trend, with highest values after five years for diabetes patients without comorbidity (p = 0.005). The number of diseases did not influence the HbA1C trend (p = 0.075). Comorbid musculoskeletal disease resulted in lower HbA1C at the time of diabetes diagnosis, but in higher values after five years (p = 0.044). Patients with cardiovascular diseases had sustained elevated levels of SBP (p = 0.014). Effect modification by socioeconomic status was observed in some comorbidity subgroups. Conclusions Presence of comorbidity in type 2 diabetes patients affected the long-term course of HbA1C and SBP in this primary care cohort. Numbers and types of comorbidity showed differential effects: not the simple sum of diseases, but specific types of comorbid disease had a negative influence on long-term diabetes control parameters. The complex interactions between comorbidity, diabetes control and effect modifiers require further investigation and may help to personalize treatment goals

The Importance of Evaluating Primary Midwifery Care for Improving the Health of Women and Infants

In most countries, maternal and newborn care is fragmented and focused on identification and treatment of pathology that affects only the minority of women and babies. Recently, a Framework for Quality Maternal and Newborn Care (QMNC) was developed, which encourages a system-level shift to provide skilled care for all. This care includes preventive and supportive care that works to strengthen women’s capabilities and focuses on promotion of normal reproductive processes while ensuring access to emergency treatment when needed. Midwifery care is pivotal in this framework which contains several elements that resonate with the main dimensions of primary care. Primary health care is the first level of contact with the health system where most of the population’s curative and preventive health needs can be fulfilled as close as possible to where people live and work. In this paper, we argue that midwifery as described in the framework requires the application of a primary care philosophy for all childbearing women and infants. Evaluation of the implementation of the framework should therefore include tools to monitor the performance of primary midwifery care

Fully Dynamic Numerical Simulation of the Hammer Peening Fatigue Life Improvement Technique

AbstractThis paper presents the results of the development process for a Finite Element Analysis of the Hammer Peening Fatigue Life Improvement Technique. The Fatigue Life of welded structures is still in need for improvement. The sheer number of Fatigue Live Improvement Techniques parameters leads to the need of simulating and predicting their results. For this study, two different materials were used, an Austenitic Stainless Steel and a Duplex Stainless Steel. Non-load carrying cruciform weld joints were produced and fatigue tested, with and without the Hammer Peening treatment. Finally a FEA code (ABAQUS®) was used to simulate the Hammer Peening technique. A fully dynamic model was used, combined with the Chaboche Kinematic-hardening material model and different Hammering parameter experimentally determined. Alongside the residual stresses introduced by the Hammer Peening Technique, the predicted Fatigue Life using the FEA model were compared with the experimental results, showing a very good agreement between them. Also the effect of several parameters, like the hammering impact load, the hammer positioning or the number of hammering passages, were analysed as a way to validate the FEA model. The most important result was of course the Fatigue Strength Gain factor, for the Hammer Peening Technique, that in both cases was found to be superior to 1.3

The diagnostic pathway of Parkinson's disease: A cross-sectional survey study of factors influencing patient dissatisfaction

Background: The diagnostic pathway of Parkinson’s disease (PD) is often complicated. Experiences during this pathway can affect patients’ satisfaction and their confidence and trust in healthcare providers. Although healthcare providers cannot influence the impact of the diagnosis, they can influence how patients experience the pathway. This study, therefore, aims to provide insight into PD patients’ dissatisfaction with the diagnostic pathway and to describe the factors that influence it. Methods: We carried out a cross-sectional survey study among 902 patient members of the Dutch Parkinson’s Disease Association, who were each asked to write an essay about their diagnostic pathway. A coding format was developed to examine the content of these essays. Inter-observer agreement on coding patient dissatisfaction was calculated using Cohen’s kappa. The χ2 test and a multivariable logistic regression analysis were performed to assess the relation between dissatisfaction and sex, level of education, duration of the pathway, communication with the general practitioner (GP) and the neurologist, the number of healthcare providers involved, whether or not a second opinion had taken place (including the person who initiated it) and diagnostic delay (taking into consideration who caused the delay according to the patient). A subgroup analysis was performed to gain insight into sex-related differences. Results: Of all patients, 16.4% explicitly described they were dissatisfied with the diagnostic pathway, whereas 4.8% were very satisfied. The inter-observer agreement on coding dissatisfaction was κ = 0.82. The chance of dissatisfaction increased with a lower level of education, the involvement of more than one additional healthcare provider, a second opinion initiated by the patient and delay caused by a healthcare provider. When only the GP and the neurologist were involved, women were more likely to be dissatisfied than men. Conclusions: PD patients’ dissatisfaction with the diagnostic pathway is related to a lower level of education, a second opinion initiated by the patient and experienced diagnostic delay. GPs can positively influence patients’ experiences if they are aware of these risk factors for dissatisfaction and pay extra attention to communication and shared decision making. This will contribute to a trusting therapeutic relationship that is indispensable with progression of the diseaseThis study was supported by funds of the Dutch Parkinson’s Disease Association (Funding number 2012-V15) and the Health Insurers Innovation Foundation (Funding number 2687)

Implementing mentor mothers in family practice to support abused mothers: Study protocol

Contains fulltext : 97988.pdf (postprint version ) (Open Access)ABSTRACT: BACKGROUND: Intimate partner violence is highly prevalent and mostly affects women with negative consequences for their physical and mental health. Children often witness the violence which has negative consequences for their well-being too. Care offered by family physicians is often rejected because abused women experience a too high threshold. Mentor mother support, a low threshold intervention for abused mothers in family practice, proved to be feasible and effective in Rotterdam, the Netherlands. The primary aim of this study is to investigate which factors facilitate or hinder the implementation of mentor mother support in family practice. Besides we evaluate the effect of mentor mother support in a different region. METHODS/DESIGN: An observational study with pre- and posttests will be performed. Mothers with home living children or pregnant women who are victims of intimate partner violence will be offered mentor mother support by the participating family physicians. The implementation process evaluation consists of focus groups, interviews and questionnaires. In the effect evaluation intimate partner violence, the general health of the abused mother, the mother-child relationship, social support, and acceptance of professional help will be measured twice (t = 0 and t = 6 months) by questionnaires, reporting forms, medical records and interviews with the abused mothers. Qualitative coding will be used to analyze the data from the reporting forms, medical records, focus groups, interviews, and questionnaires. Quantitative data will be analyzed with descriptive statistics, chi square test and t-test matched pairs. DISCUSSION: While other intervention studies only evaluate the feasibility and effectiveness of the intervention, our primary aim is to evaluate the implementation process and thereby investigate which factors facilitate or hinder implementation of mentor mother support in family practice.6 p