General practitioners' perceptions of effective health care

Objectives: To explore general practitioners' perceptions of effective health care and its application in their own practice; to examine how these perceptions relate to assumptions about clinicians' values and behaviour implicit in the evidence based medicine approach. Design: A qualitative study using semistructured interviews. Setting: Eight general practices in North Thames region that were part of the Medical Research Council General Practice Research Framework. Participants: 24 general practitioners, three from each practice. Main outcome measures: Respondents' definitions of effective health care, reasons for not practising effectively according to their own criteria, sources of information used to answer clinical questions about patients, reasons for making changes in clinical practice. Results: Three categories of definitions emerged: clinical, patient related, and resource related. Patient factors were the main reason given for not practising effectively; others were lack of time, doctors' lack of knowledge and skills, lack of resources, and "human failings." Main sources of information used in situations of clinical uncertainty were general practitioner partners and hospital doctors. Contact with hospital doctors and observation of hospital practice were just as likely as information from medical and scientific literature to bring about changes in clinical practice. Conclusions: The findings suggest that the central assumptions of the evidence based medicine paradigm may not be shared by many general practitioners, making its application in general practice problematic. The promotion of effective care in general practice requires a broader vision and a more pragmatic approach which takes account of practitioners' concerns and is compatible with the complex nature of their work

Global sensitivity analysis of detailed chemical kinetic schemes for DME oxidation in premixed flames

Detailed chemical kinetic investigations on dimethylether oxidation in one-dimensional premixed flat flames were performed. Local and global sensitivities of the reaction rate constants within selected chemical kinetic schemes were studied using maximum flame temperature, and peak methane and formaldehyde concentrations as predictive target quantities. The global sensitivity analysis was based on the application of high dimensional model representations using quasi-random sampling. First- and second-order sensitivity indices of important reaction steps were determined for fuel rich (Φ = 1.49) and fuel lean (Φ = 0.67) conditions. Differences in the importance ranking for key reactions were found to exist between the selected schemes, highlighting the influence of differences in the key rate constants. Whilst the peak flame temperature was predicted with fairly low uncertainty by both schemes, significant uncertainties were identified in the prediction of the target minor species. Key reaction rates requiring better quantification in order to improve the prediction of methane and formaldehyde concentrations are identified

Proton Drip-Line Calculations and the Rp-process

One-proton and two-proton separation energies are calculated for proton-rich nuclei in the region $A=41-75$. The method is based on Skyrme Hartree-Fock calculations of Coulomb displacement energies of mirror nuclei in combination with the experimental masses of the neutron-rich nuclei. The implications for the proton drip line and the astrophysical rp-process are discussed. This is done within the framework of a detailed analysis of the sensitivity of rp process calculations in type I X-ray burst models on nuclear masses. We find that the remaining mass uncertainties, in particular for some nuclei with $N=Z$, still lead to large uncertainties in calculations of X-ray burst light curves. Further experimental or theoretical improvements of nuclear mass data are necessary before observed X-ray burst light curves can be used to obtain quantitative constraints on ignition conditions and neutron star properties. We identify a list of nuclei for which improved mass data would be most important.Comment: 20 pages, 9 figures, 2 table

Degradation of metalaxyl and folpet by filamentous fungi isolated from Portuguese (Alentejo) vineyard soils

Degradation of xenobiotics by microbial populations is a potential method to enhance the effectiveness of ex situ or in situ bioremediation. The purpose of this study was to evaluate the impact of repeated metalaxyl and folpet treatments on soil microbial communities and to select soil fungal strains able to degrade these fungicides. Results showed enhanced degradation of metalaxyl and folpet in vineyards soils submitted to repeated treatments with these fungicides. Indeed, the greatest degradation ability was observed in vineyard soil samples submitted to greater numbers of treatments. Respiration activities, as determined in the presence of selective antibiotics in soil suspensions amended with metalaxyl and folpet, showed that the fungal population was the microbiota community most active in the degradation process. Batch cultures performed with a progressive increase of fungicide concentrations allowed the selection of five tolerant fungal strains: Penicillium sp. 1 and Penicillium sp. 2, mycelia sterila 1 and 3, and Rhizopus stolonifer. Among these strains, mycelium sterila 3 and R. stolonifer presented only in vineyard soils treated with repeated application of these fungicides and showed tolerance >1,000 mg l−1 against commercial formulations of metalaxyl (10 %) plus folpet (40 %). Using specific methods for inducing sporulation, mycelium sterila 3 was identified as Gongronella sp. Because this fungus is rare, it was compared using csM13-polymerase chain reaction (PCR) with the two known species, Gongronella butleri and G. lacrispora. The high tolerance to metalaxyl and folpet shown by Gongronella sp. and R. stolonifer might be correlated with their degradation ability. Our results point out that selected strains have potential for the bioremediation of metalaxyl and folpet in polluted soil sites

Determination of diquat by flow injection-chemiluminescence

A simple, economic, sensitive and rapid method for the determination of the pesticide diquat was described. This new method was based on the coupling of flow injection analysis methodology and direct chemiluminescent detection; to the authors' knowledge, this approach had not been used up to now with this pesticide. It was based on its oxidation with ferricyanide in alkaline medium; significant improvements in the analytical signal were achieved by using high temperatures and quinine as sensitiser. Its high throughput (144 h(-1)), together with its low limit of detection (2 ng mL(-1)), achieved without need of preconcentration steps, permitted the reliable quantification of diquat over the linear range of (0.01-0.6) mu g mL(-1) in samples from different origins (river, tap, mineral and ground waters), even in the presence of a 40-fold concentration of paraquat, a pesticide commonly present in the commercial formulations of diquat.López-Paz, JL.; Catalá-Icardo, M.; Antón Garrido, B. (2009). Determination of diquat by flow injection-chemiluminescence. Analytical and Bioanalytical Chemistry. 394(4):1073-1079. doi:10.1007/s00216-009-2609-zS107310793944Hayes WJ Jr, Laws ER Jr (1991) Handbook of pesticide toxicology, Academic Press, San DiegoUS Environmental Protection Agency. http://www.epa.gov/06WDW/contaminants/dw_contamfs/diquat.html (accessed in August 2008)Horwitz W (2000) Official methods of analysis of AOAC International 17th edition. AOAC International, Gaithersburg, MD, USAHara S, Sasaki N, Takase D, Shiotsuka S, Ogata K, Futagami K, Tamura K (2007) Anal Sci 23(5):523–531Rial Otero R, Cancho Grande B, Pérez Lamela C, Simal Gandara J, Aria Estevez M (2006) J Chromatogr Sci 44(9):539–542Aramendia MA, Borau V, Lafont F, Marinas JM, Moreno JM, Porras JM, Urbano FJ (2006) Food Chem 97(1):181–188Nuñez O, Moyano E, Galceran MT (2004) Anal Chim Acta 525(2):183–190Martinez Vidal JL, Belmonte Vega A, Sanchez Lopez FJ, Garrido Frenich AJ (2004) Chromatogr A 1050(2):179–184Lee XP, Kumazawa T, Fujishiro M, Hasegawa C, Arinobu T, Seno H, Sato K (2004) J Mass Spectrom 39(10):1147–1152De Almeida RM, Yonamine M (2007) J Chromatogr B 853(1–2):260–264De Souza D, Machado SAS (2006) Electroanalysis 18(9):862–872De Souza D, Da Silva MRC, Machado SAS (2006) Electroanalysis 18(23):2305–2313Picó Y, Rodriguez R, Manes J (2003) Trends Anal Chem 22(3):133–151Ishiwata T (2004) Bunseki Kagaku 53(8):863–864Carneiro MC, Puignou L, Galcerán MT (2000) Anal Chim Acta 408:263Luque M, Rios A, Valcarcel M (1998) Analyst 123(11):2383–2387Perez Ruiz T, Martínez Lozano C, Tomas V (1991) Int J Environ Anal Chem 44(4):243–252Perez Ruiz T, Martínez Lozano C, Tomas V (1991) Anal Chim Acta 244(1):99–104Townshend A (1990) Analyst 115:495–500López Paz JL, Catalá Icardo M (2008) Anal Chim Acta 625:173–179Pawlicová Z, Sahuquillo I, Catalá Icardo M, García Mateo JV, Martínez Calatayud J (2006) Anal Sci 22:29–34Albert García JR, Catalá Icardo M, Martínez Calatayud J (2006) Talanta 69:608–614Tomlin CDS (1997) The pesticide manual, 11th edn.The British Crop Protection CouncilUKCatalá-Icardo M, Martínez-Calatayud J (2008) Crit Rev Anal Chem 38:118–130Ministerio de Medio Ambiente y Medio Rural y Marino. http://www.marm.es/ (accessed in September 2008)US Environmental Protection Agency. http://www.epa.gov/OGWWDW/contaminants (accessed in October 2008

The potential for research-based information in public health: Identifying unrecognised information needs

OBJECTIVE: To explore whether there is a potential for greater use of research-based information in public health practice in a local setting. Secondly, if research-based information is relevant, to explore the extent to which this generates questioning behaviour. DESIGN: Qualitative study using focus group discussions, observation and interviews. SETTING: Public health practices in Norway. PARTICIPANTS: 52 public health practitioners. RESULTS: In general, the public health practitioners had a positive attitude towards research-based information, but believed that they had few cases requiring this type of information. They did say, however, that there might be a potential for greater use. During five focus groups and six observation days we identified 28 questions/cases where it would have been appropriate to seek out research evidence according to our definition. Three of the public health practitioners identified three of these 28 cases as questions for which research-based information could have been relevant. This gap is interpreted as representing unrecognised information needs. CONCLUSIONS: There is an unrealised potential in public health practice for more frequent and extensive use of research-based information. The practitioners did not appear to reflect on the need for scientific information when faced with new cases and few questions of this type were generated

Impact of pharmaceutical promotion on prescribing decisions of general practitioners in Eastern Turkey

<p>Abstract</p> <p>Background</p> <p>Commercial sources of information are known to have greater influence than scientific sources on general practitioners' (GPs) prescribing behavior in under developed and developing countries. The study aimed to determine the self-reported impact of pharmaceutical promotion on the decision-making process of prescription of GPs in Eastern Turkey.</p> <p>Methods</p> <p>A cross-sectional, exploratory survey was performed among 152 GPs working in the primary health centers and hospitals in Erzurum province of Eastern Turkey in 2006. A self-administered structured questionnaire was used. The questionnaire included questions regarding sociodemographics, number of patients per day, time per patient, frequency of sales representative visits to GPs, participation of GPs in training courses on prescribing (in-service training, drug companies), factors affecting prescribing decision, reference sources concerning prescribing and self-reported and self-rated effect of the activities of sales representatives on GPs prescribing decisions.</p> <p>Results</p> <p>Of 152 subjects, 53.3% were male and 65.8% were working at primary health care centers, respectively. Mean patient per day was 58.3 ± 28.8 patients per GP. For majority of the GPs (73.7%), the most frequent resource used in case of any problems in prescribing process was drug guides of pharmaceutical companies. According to self-report of the GPs, their prescribing decisions were affected by participation in any training activity of drug companies, frequent visits by sales representatives, high number of patient examinations per day and low year of practice (p < 0.05 for all).</p> <p>Conclusion</p> <p>The results of this study suggest that for the majority of the GPs, primary reference sources concerning prescribing was commercial information provided by sales representatives of pharmaceutical companies, which were reported to be highly influential on their decision-making process of prescribing by GPs. Since this study was based on self-report, the influence reported by the GPs may have been underestimated.</p

Motives and preferences of general practitioners for new collaboration models with medical specialists: a qualitative study

BACKGROUND: Collaboration between general practitioners (GPs) and specialists has been the focus of many collaborative care projects during the past decade. Unfortunately, quite a number of these projects failed. This raises the question of what motivates GPs to initiate and continue participating with medical specialists in new collaborative care models. The following two questions are addressed in this study: What motivates GPs to initiate and sustain new models for collaborating with medical specialists? What kind of new collaboration models do GPs suggest? METHODS: A qualitative study design was used. Starting in 2003 and finishing in 2005, we conducted semi-structured interviews with a purposive sample of 21 Dutch GPs. The sampling criteria were age, gender, type of practice, and practice site. The interviews were recorded, fully transcribed, and analysed by two researchers working independently. The resulting motivational factors and preferences were grouped into categories. RESULTS: 'Developing personal relationships' and 'gaining mutual respect' appeared to dominate when the motivational factors were considered. Besides developing personal relationships with specialists, the GPs were also interested in familiarizing specialists with the competencies attached to the profession of family medicine. Additionally, they were eager to increase their medical knowledge to the benefit of their patients. The GPs stated a variety of preferences with respect to the design of new models of collaboration. CONCLUSION: Developing personal relationships with specialists appeared to be one of the dominant motives for increased collaboration. Once the relationships have been formed, an informal network with occasional professional contact seemed sufficient. Although GPs are interested in increasing their knowledge, once they have reached a certain level of expertise, they shift their focus to another specialty. The preferences for new collaboration models are diverse. A possible explanation for the differences in the preferences is that professionals are more knowledge driven than organisation driven as the acquiring of new knowledge is considered more important than the route by which this is achieved. A new collaboration model seems a way to acquire knowledge. Once this is achieved the importance of a model possibly diminishes, whereas the professional relationships last

Implementing evidence-based medicine in general practice: a focus group based study

BACKGROUND: Over the past years concerns are rising about the use of Evidence-Based Medicine (EBM) in health care. The calls for an increase in the practice of EBM, seem to be obstructed by many barriers preventing the implementation of evidence-based thinking and acting in general practice. This study aims to explore the barriers of Flemish GPs (General Practitioners) to the implementation of EBM in routine clinical work and to identify possible strategies for integrating EBM in daily work. METHODS: We used a qualitative research strategy to gather and analyse data. We organised focus groups between September 2002 and April 2003. The focus group data were analysed using a combined strategy of 'between-case' analysis and 'grounded theory approach'. Thirty-one general practitioners participated in four focus groups. Purposeful sampling was used to recruit participants. RESULTS: A basic classification model documents the influencing factors and actors on a micro-, meso- as well as macro-level. Patients, colleagues, competences, logistics and time were identified on the micro-level (the GPs' individual practice), commercial and consumer organisations on the meso-level (institutions, organisations) and health care policy, media and specific characteristics of evidence on the macro-level (policy level and international scientific community). Existing barriers and possible strategies to overcome these barriers were described. CONCLUSION: In order to implement EBM in routine general practice, an integrated approach on different levels needs to be developed