Objective. To explore views and attitudes among general practitioners (GPs) and researchers in the field of general practice towards problems and challenges related to treatment of patients with multimorbidity. Setting. A workshop entitled Patients with multimorbidity in general practice held during the Nordic Congress of General Practice in Tampere, Finland, 2013. Subjects. A total of 180 GPs and researchers. Design. Data for this summary report originate from audio-recorded, transcribed verbatim plenary discussions as well as 76 short questionnaires answered by attendees during the workshop. The data were analysed using framework analysis. Results. (i) Complex care pathways and clinical guidelines developed for single diseases were identified as very challenging when handling patients with multimorbidity; (ii) insufficient cooperation between the professionals involved in the care of multimorbid patients underlined the GPs’ impression of a fragmented health care system; (iii) GPs found it challenging to establish a good dialogue and prioritize problems with patients within the timeframe of a normal consultation; (iv) the future role of the GP was discussed in relation to diminishing health inequality, and current payment systems were criticized for not matching the treatment patterns of patients with multimorbidity. Conclusion. The participants supported the development of a future research strategy to improve the treatment of patients with multimorbidity. Four main areas were identified, which need to be investigated further to improve care for this steadily growing patient group.
Our results suggest that dietary n-6 PUFA are not as readily transferred into breast milk or incorporated into serum phospholipids, but may be utilized for other purposes, such as eicosanoid precursors, in allergic/atopic individuals. Subsequently, high dietary proportions of n-6 PUFA, or reduced proportions of regulatory PUFA, such as gamma-linolenic acid and n-3 PUFA, may be a risk factor for the development of atopic disease.
Areal bone mineral density (BMD, g/cm(2)) of five healthy women (aged 26-30 years) was measured at the lumbar spine, right femoral neck and dominant distal radius with dual-energy X-ray absorptiometry before pregnancy, immediately after delivery, 1 month after the resumption of menses and 1 year thereafter. Because of the small number of subjects, only individual changes in BMD that were greater than 2 radical2 times the short-term in vivo precision were considered as significant changes. To obtain a further perspective, the reproduction-related BMD changes were compared with twice the standard deviation (SD) of the BMD changes in healthy premenopausal women (about +/- 5%), and with the SD of the BMD in a cross-sectional sample of young healthy women. The duration of postpartum amenorrhea (PPA) and of lactation in our subjects ranged from about 2 months to 1 year and from 5 months to almost 2 years, respectively. No clear association between PPA and lactation could be seen. The magnitudes of reproduction-related BMD changes in general seemed not to differ substantially from about +/- 5% variability in BMD changes in healthy nonpregnant and nonlactating women. There was, however, some tendency toward systematic bone loss at the lumbar spine (about -3%) during pregnancy and at the femoral neck during PPA (about -5% as compared with prepregnancy data). Some individuals can yet show large, systematic bone losses comparable to 1 SD in magnitude. The site-specific reproduction-induced bone loss and consequent recovery are apparently multifactorial phenomena that may be related not only to duration and magnitude of lactation and/or duration of postpartum amenorrhea, but also to prevailing biomechanical and dietary factors, and other yet unknown individually modulated factors.
BackgroundThe aim here was to explore trends in patient satisfaction with primary health care and its accessibility and continuity, and to explore whether through reforms and improvements some of the essential goals had been achieved over a 14-year period of time in Finland.MethodsNine questionnaire surveys were conducted over a period of 14 years among patients attending within one week in the 65 health centres in the Tampere University Hospital catchment area. A total of 147,394 responded out of a sample of 333,648 patients. The response rate varied yearly from 53% to 37%.ResultsPatient satisfaction with care in Finnish health centres decreased by nearly 9 percentage units from 1998 to 2011. The fall-off was most marked in the age-group over 64 years. There was a 20 percentage unit’s reduction in ease of access as reported by patients. Respondents also reported that the continuity of care had deteriorated.ConclusionsDespite major reforms in Finnish health care policy, patients seem to be less satisfied. Our findings challenge both Finnish authorities and GPs to improve the accessibility and continuity of care in primary health services.
Changes in bone turnover, and consequent bone loss and recovery during lactation and the postweaning period, are likely modulated by varying estrogen levels inherent in these time periods. To address this question we measured serum biochemical markers of bone formation (bone-specific alkaline phosphatase, amino-terminal propeptide of type I procollagen, osteocalcin), of bone resorption (type I collagen carboxy-terminal telopeptide), and serum female sex hormones (estradiol, luteinizing hormone and follicle-stimulating hormone) in 32 healthy mothers prospectively after delivery, 3 months postpartum, after postpartum amenorrhea and 1 year after resumption of menses. During postpartum amenorrhea (mean 5.7, SD 2.9 months) bone mineral density decreased significantly, some 2% at the lumbar spine and some 3% at the femoral neck, but subsequently recovered completely at the former site and partially at the latter. Bone turnover marker levels were elevated at parturition and still at the end of postpartum amenorrhea. Subsequent to parturition the bone resorption marker level showed a decreasing trend while the formation marker levels continued increasing, and eventually coincided with the resorption level within the very first months postpartum. Both lactation and hormonal status modulated bone turnover marker levels. Maternal age was positively associated with increased bone turnover. Interestingly, higher parity and longer history of previous lactation were associated with lower bone turnover marker levels postpartum as compared with previously nulliparous women of the same age. The regression models explained typically some 20-30% of the variability in the bone turnover marker levels. The dynamic pattern in bone turnover is dissimilar to that occurring at menopause and it indicates that the bone loss most likely occurs in the beginning of postpartum period. It also seems that estrogen has a specific influence on bone turnover only during the first months of lactation.
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