Continuous professional development (CPD) for Danish general practitioners (GPs) is voluntary and based on funded accredited activities. There is an ongoing discussion on how to improve this current ...system by introducing mandatory elements. To inform this debate, we set out to identify GPs' current use of CPD and to explore the motives behind their choices.
A mixed-methods study with a combined qualitative and quantitative approach was used. In 2012, two focus group interviews were conducted, followed up the same year by an online questionnaire sent to 1079 randomly chosen Danish GPs.
Focus groups: CPD activities are chosen based on personal needs analysis, and in order to be professionally updated, to meet engaged colleagues and to prevent burnout. GPs also attend CPD to assess their own pre-existing level of competence. CPD activities need to be experienced as being both meaningful and relevant in order to have an impact. Questionnaire: The response rate was 686/1079 (63%). GPs spend on average 10.5 days per year on accredited, voluntary CPD activities. Workplace-related CPD activities and practice-based small group learning played a significant role. The main motivation for choice of CPD activities included academic interest, experience of patient-related problems in their own surgeries and medical topics where the GPs felt insufficiently confident.
Danish GPs are frequent users of voluntary accredited CPD. Their CPD choices are motivated by topics strengthening their professional capacity and preventing burnout. There would seem to be no need for a mandatory system.
Background Measurement of serum concentrations of drugs is a novelty found useful in detecting poor drug adherence in patients taking ≥2 antihypertensive agents. Regarding patients with ...treatment-resistant hypertension, we previously based our assessment on directly observed therapy. The present study aimed to investigate whether serum drug measurements in patients with resistant hypertension offer additional information regarding drug adherence, beyond that of initial assessment with directly observed therapy. Methods and Results Nineteen patients assumed to have true treatment-resistant hypertension and adherence to antihypertensive drugs based on directly observed therapy were investigated repeatedly through 7 years. Serum concentrations of antihypertensive drugs were measured by ultra-high-performance liquid chromatography-tandem mass spectrometry from blood samples taken at baseline, 6-month, 3-year, and 7-year visits. Cytochrome P450 polymorphisms, self-reported adherence and beliefs about medicine were performed as supplement investigations. Seven patients (37%) were redefined as nonadherent based on their serum concentrations during follow-up. All patients reported high adherence to medications. Nonadherent patients expressed lower necessity and higher concerns regarding intake of antihypertensive medication (
=0.003). Cytochrome P450 polymorphisms affecting metabolism of antihypertensive drugs were found in 16 patients (84%), 21% were poor metabolizers, and none were ultra-rapid metabolizers. Six of 7 patients redefined as nonadherent had cytochrome P450 polymorphisms, however, not explaining the low serum drug concentrations measured in these patients. Conclusions Our data suggest that repeated measurements of serum concentrations of antihypertensive drugs revealed nonadherence in one-third of patients previously evaluated as adherent and treatment resistant by directly observed therapy, thereby improving the accuracy of adherence evaluation. Registration URL: https://www.clinicaltrials.gov; unique identifier: NCT01673516.
We aimed to investigate for the first time the blood pressure (BP)-lowering effect of renal sympathetic denervation (RDN) versus clinically adjusted drug treatment in true treatment-resistant ...hypertension (TRH) after excluding patients with confounding poor drug adherence. Patients with apparent TRH (n=65) were referred for RDN, and those with secondary and spurious hypertension (n=26) were excluded. TRH was defined as office systolic BP (SBP) >140 mm Hg, despite maximally tolerated doses of ≥3 antihypertensive drugs including a diuretic. In addition, ambulatory daytime SBP >135 mm Hg after witnessed intake of antihypertensive drugs was required, after which 20 patients had normalized BP and were excluded. Patients with true TRH were randomized and underwent RDN (n=9) performed with Symplicity Catheter System versus clinically adjusted drug treatment (n=10). The study was stopped early for ethical reasons because RDN had uncertain BP-lowering effect. Office SBP and diastolic BP in the drug-adjusted group changed from 160±14/88±13 mm Hg (±SD) at baseline to 132±10/77±8 mm Hg at 6 months (P<0.0005 and P=0.02, SBP and diastolic BP, respectively) and in the RDN group from 156±13/91±15 to 148±7/89±8 mm Hg (P=0.42 and P=0.48, SBP and diastolic BP, respectively). SBP and diastolic BP were significantly lower in the drug-adjusted group at 6 months (P=0.002 and P=0.004, respectively), and absolute changes in SBP were larger in the drug-adjusted group (P=0.008). Ambulatory BPs changed in parallel to office BPs. Our data suggest that adjusted drug treatment has superior BP lowering effects compared with RDN in patients with true TRH. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT01673516.
Randomized clinical trials (RCTs) conducted in adult ICU patients increasingly include patient-important outcomes other than mortality. This comes with challenges regarding outcome ...choices/definitions, handling of deceased patients and missing data in analyses, and choices of effect measures and statistical methods due to complex distributions. This scoping review aimed to characterize how these challenges are handled in relevant contemporary RCTs.
We systematically searched 10 selected journals for RCTs conducted primarily in adult ICU patients published between 1 January 2018 and 5 May 2022 reporting at least one patient-important outcome other than mortality, including "days alive without"…-type outcomes, functional/cognitive/neurologic outcomes, health-related quality of life (HRQoL) outcomes, and ordinal/other outcomes.
Abstracts and full-texts were assessed independently and in duplicate by two reviewers.
Data were extracted independently and in duplicate by two reviewers using predefined and pilot-tested extraction forms and subsequently categorized to facilitate analysis.
We included 687 outcomes from 167 RCTs, with 32% of RCTs using a patient-important outcome other than mortality as a (co-)primary outcome, most frequently "days alive without"…-type outcomes. Many different functional/cognitive/neurologic (103) and HRQoL (29) outcomes were reported. Handling of deceased patients varied, with analyses frequently restricted to survivors only for functional/cognitive/neurologic (62%) and HRQoL (89%) outcomes. Follow-up was generally longer and missing data proportions higher for functional/cognitive/neurologic and HRQoL outcomes. Most outcomes were analyzed using nonparametric tests (31%), linear regression/ t tests (27%), chi-square-like tests (12%), and proportional odds logistic regression (9%), often without presentation of actual treatment effects estimates (38%).
In this sample of RCTs, substantial variation in practice and suboptimal methodological choices were observed. This calls for increased focus on standardizing outcome choices and definitions, adequate handling of missing data and deceased patients in analyses, and use of statistical methods quantifying effect sizes.
Background
The CLASSIC trial assessed the effects of restrictive versus standard intravenous (IV) fluid therapy in adult intensive care unit (ICU) patients with septic shock. This pre‐planned study ...provides a probabilistic interpretation and evaluates heterogeneity in treatment effects (HTE).
Methods
We analysed mortality, serious adverse events (SAEs), serious adverse reactions (SARs) and days alive without life‐support within 90 days using Bayesian models with weakly informative priors. HTE on mortality was assessed according to five baseline variables: disease severity, vasopressor dose, lactate levels, creatinine values and IV fluid volumes given before randomisation.
Results
The absolute difference in mortality was 0.2%‐points (95% credible interval: −5.0 to 5.4; 47% posterior probability of benefit risk difference <0.0%‐points) with restrictive IV fluid. The posterior probabilities of benefits with restrictive IV fluid were 72% for SAEs, 52% for SARs and 61% for days alive without life‐support. The posterior probabilities of no clinically important differences (absolute risk difference ≤2%‐points) between the groups were 56% for mortality, 49% for SAEs, 90% for SARs and 38% for days alive without life‐support. There was 97% probability of HTE for previous IV fluid volumes analysed continuously, that is, potentially relatively lower mortality of restrictive IV fluids with higher previous IV fluids. No substantial evidence of HTE was found in the other analyses.
Conclusion
We could not rule out clinically important effects of restrictive IV fluid therapy on mortality, SAEs or days alive without life‐support, but substantial effects on SARs were unlikely. IV fluids given before randomisation might interact with IV fluid strategy.
It is unknown whether the decline in blood pressure (BP) after renal denervation (RDN) is caused by denervation itself or concomitantly improved drug adherence. We aimed to investigate the BP ...lowering effect of RDN in true treatment-resistant hypertension by excluding patients with poor drug adherence. Patients with resistant hypertension (n=18) were referred for a thorough clinical and laboratory work-up. Treatment-resistant hypertension was defined as office systolic BP>140 mm Hg, despite maximally tolerated doses of ≥ 3 antihypertensive drugs, including a diuretic. In addition, ambulatory daytime systolic BP>135 mm Hg was required after witnessed intake of antihypertensive drugs to qualify. RDN (n=6) was performed with Symplicity Catheter System. The mean office and ambulatory BPs remained unchanged at 1, 3, and 6 months in the 6 patients, whereas there was no known change in antihypertensive medication. Two patients, however, had a fall in both office and ambulatory BPs. Our findings question whether BP falls in response to RDN in patients with true treatment-resistant hypertension. Additional research must aim to verify potential BP lowering effect and identify a priori responders to RDN before this invasive method can routinely be applied to patients with drug-resistant hypertension. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT01673516.
Future perspectives on psychiatry Kristiansen, C. B.; Kjær, J. N.; Medici, C. R. ...
Acta psychiatrica Scandinavica,
01/2015, Letnik:
131, Številka:
1
Journal Article
Variation in usual practice in fluid trials assessing lower versus higher volumes may affect overall comparisons. To address this, we will evaluate the effects of heterogeneity in treatment intensity ...in the Conservative versus Liberal Approach to Fluid Therapy of Septic Shock in Intensive Care trial. This will reflect the effects of differences in site-specific intensities of standard fluid treatment due to local practice preferences while considering participant characteristics.
We will assess the effects of heterogeneity in treatment intensity across one primary (all-cause mortality) and three secondary outcomes (serious adverse events or reactions, days alive without life support and days alive out of hospital) after 90 days. We will classify sites based on the site-specific intensity of standard fluid treatment, defined as the mean differences in observed versus predicted intravenous fluid volumes in the first 24 h in the standard-fluid group while accounting for differences in participant characteristics. Predictions will be made using a machine learning model including 22 baseline predictors using the extreme gradient boosting algorithm. Subsequently, sites will be grouped into fluid treatment intensity subgroups containing at least 100 participants each. Subgroups differences will be assessed using hierarchical Bayesian regression models with weakly informative priors. We will present the full posterior distributions of relative (risk ratios and ratios of means) and absolute differences (risk differences and mean differences) in each subgroup.
This study will provide data on the effects of heterogeneity in treatment intensity while accounting for patient characteristics in critically ill adult patients with septic shock.
The European Clinical Trials Database (EudraCT): 2018-000404-42, ClinicalTrials. gov: NCT03668236.
Introduction
Psychodynamic psychotherapy emphasizes the unique history, subjectivity, and psychological complexity of each individual. The core principles in the psychodynamic treatment of ...schizophrenia spectrum disorders (SSD) includes a stable (yet flexible) frame; attention to countertransference; and clarification of experiences, emotions, and relationships including giving psychotic symptoms context in internal and external object relationships.
Objectives
This study has two aims. First, to present the progress of a patient with chronic schizophrenia treated with psychodynamic psychotherapy. Second, to provide a systematic review of comparative trials that have included psychodynamic psychotherapy as treatment for SSD.
Methods
The case presentation includes information from the therapist’s notes, video footage, and the electronic health record. The systematic review will be conducted in November and December, 2022, and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. The databases of MEDLINE, EMBASE, and PsycInfo will be searched for literature.
Results
L, a 25-year-old woman, was diagnosed with paranoid schizophrenia five years prior to starting psychodynamic psychotherapy at an outpatient unit for SSD. L grew up with a close relationship with her mother, father, and sister. She was bullied in school and clearly remembered being told by her classmates that she was “just L”. When therapy began L had been living with her boyfriend for six months. Voice hallucinations were one of the most interfering symptoms. The most present voice, M, was both her best friend and worst enemy. During psychotic breakdowns M could take control of L’s body. L was incapable of making her own decisions. Small and big decisions were consulted with a family member or the hallucinatory voices. L attended 33 psychotherapy sessions from October, 2020 to November, 2021. In the first six months, sessions were weekly and afterwards biweekly due to L feeling significantly better and she wanted to have more time to study. L benefitted from the structure and clarifying questions from the therapist. Most notably, she broke up with her boyfriend. She started dating and found a new boyfriend. At this point the voice hallucinations and psychotic breakdowns were reduced considerably. In the termination phase the themes were feeling insecure, relationships, and how having been bullied affected her as an adult.
Results from the systematic review are not available at the time of submission.
Conclusions
In the present case, psychodynamic psychotherapy was an effective treatment of psychotic symptoms as well as childhood trauma and interpersonal conflicts for an individual with paranoid schizophrenia. It speaks for a broad application of psychodynamic psychotherapy in the treatment of SSD as the therapy both assesses and treats psychotic and non-psychotic symptoms.
Disclosure of Interest
None Declared
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