BACKGROUND:Early identification of approaching end-of-life and care planning improve outcomes at the end of life. Nevertheless, the majority of people who die are not identified in time to enable appropriate care planning. We aimed to describe the challenges general practitioners (GPs) found in providing end-of-life care; what prompted GPs to identify and discuss approaching end of life with their patient and how their practice changed.METHODS:We conducted a qualitative study of 15 Australian GPs using semi-structured interviews, examining end-of-life care of one of their randomly selected, deceased patients. Interviews were analysed using a general inductive approach.RESULTS:When a life-limiting prognosis was articulated, GPs integrated end-of-life care into their clinical care directly. Care often included a care plan developed in consultation with the patient. Even when death was not articulated, GPs were aware of approaching end of life and changed their focus to comfort of the patient. GPs generally had an informal care plan in mind, but this developed gradually and without discussing these plans with the patient. How GPs provided end-of-life care depended primarily on patient traits (eg, willingness to discuss physical decline) and the GP's characteristics (eg, experience, training and consulting style).CONCLUSIONS:GPs were aware of their patients' approaching end of life and care was adjusted accordingly. However, under certain circumstances this was not explicitly articulated and discussed. It is not clear if implicit but unarticulated end-of-life care is sufficient to meet patients' needs. Future studies should investigate this.

BACKGROUND:The health and economic burden of antimicrobial resistance (in Australia is significant. Interventions that help guide and improve appropriate prescribing for acute respiratory tract infections in the community represent an opportunity to slow the spread of resistant bacteria. Clinicians who work in primary care are potentially the most influential health care professionals to address the problem of antimicrobial resistance, because this is where most antibiotics are prescribed.METHODS:A cluster randomised trial was conducted comparing two parallel groups of 27 urban general practices in Queensland, Australia: 13 intervention and 14 control practices, with 56 and 54 general practitioners (GPs), respectively. This study evaluated an integrated, multifaceted evidence-based package of interventions implemented over a 6-month period. The evaluation included quantitative and qualitative components, and an economic analysis.RESULTS:A multimodal package of interventions resulted in a reduction of 3.81 prescriptions per GP per month. This equates to 1280.16 prescriptions for the 56GPs in the intervention practices over the 6-month period. The cost per prescription avoided was A$148. The qualitative feedback showed that the interventions were well received by the GPs and did not impact on consultation time. Providing GPs with a choice of tools might enhance their uptake and support for antimicrobial stewardship in the community.CONCLUSIONS:A multimodal package of interventions to enhance rational prescribing of antibiotics is effective, feasible and acceptable in general practice. Investment in antimicrobial stewardship strategies in primary care may ultimately provide the important returns for public health into the future.

BACKGROUND:Recurrent vulvovaginal candidiasis (RVVC) affects up to 5% of women. No comprehensive systematic review of treatments for RVVC has been published. OBJECTIVES:The primary objective was to assess the effectiveness and safety of pharmacological and non-pharmacological treatments for RVVC. The secondary objective was to assess patient preference of treatment options. SEARCH METHODS:We conducted electronic searches of bibliographic databases, including CENTRAL, MEDLINE, Embase, and CINAHL (search date 6 October 2021). We also handsearched reference lists of identified trials and contacted authors of identified trials, experts in RVVC, and manufacturers of products for vulvovaginal candidiasis. SELECTION CRITERIA:We considered all published and unpublished randomised controlled trials evaluating RVVC treatments for at least six months, in women with four or more symptomatic episodes of vulvovaginal candidiasis in the past year. We excluded women with immunosuppressive disorders or taking immunosuppressant medication. We included women with diabetes mellitus and pregnant women. Diagnosis of RVVC must have been confirmed by presence of symptoms and a positive culture and/or microscopy. We included all drug and non-drug therapies and partner treatment, assessing the following primary outcomes: • number of clinical recurrences per participant per year (recurrence defined as clinical signs and positive culture/microscopy); • proportion of participants with at least one clinical recurrence during the treatment and follow-up period; and • adverse events. DATA COLLECTION AND ANALYSIS:Two authors independently reviewed titles and abstracts to identify eligible trials. Duplicate data extraction was completed independently by two authors. We assessed risk of bias as described in the Cochrane Handbook for Systematic Reviews of Interventions. We used the fixed-effects model for pooling and expressed the results as risk ratio (RR) with 95% confidence intervals (CI). Where important statistical heterogeneity was present we either did not pool data (I2 > 70%) or used a random-effects model (I2 40-70%). We used the GRADE tool to assess overall certainty of the evidence for the pooled primary outcomes. MAIN RESULTS:Studies: Twenty-three studies involving 2212 women aged 17 to 67 years met the inclusion criteria. Most studies excluded pregnant women and women with diabetes or immunosuppression. The predominant species found on culture at study entry was Candida albicans. Overall, the included studies were small (<100 participants). Six studies compared antifungal treatment with placebo (607 participants); four studies compared oral versus topical antifungals (543 participants); one study compared different oral antifungals (45 participants); two studies compared different dosing regimens for antifungals (100 participants); one study compared two different dosing regimens of the same topical agent (23 participants); one study compared short versus longer treatment duration (26 participants); two studies assessed the effect of partner treatment (98 participants); one study compared a complementary treatment (Lactobacillus vaginal tablets and probiotic oral tablets) with placebo (34 participants); three studies compared complementary medicine with antifungals (354 participants); two studies compared 'dermasilk' briefs with cotton briefs (130 participants); one study examined Lactobacillus vaccination versus heliotherapy versus ciclopyroxolamine (90 participants); one study compared CAM treatments to an antifungal treatment combined with CAM treatments (68 participants). We did not find any studies comparing different topical antifungals. Nine studies reported industry funding, three were funded by an independent source and eleven did not report their funding source. Risk of bias: Overall, the risk of bias was high or unclear due to insufficient blinding of allocation and participants and poor reporting. Primary outcomes: Meta-analyses comparing drug treatments (oral and topical) with placebo or no treatment showed there may be a clinically relevant reduction in clinical recurrence at 6 months (RR 0.36, 95% CI 0.21 to 0.63; number needed to treat for an additional beneficial outcome (NNTB) = 2; participants = 607; studies = 6; I² = 82%; low-certainty evidence) and 12 months (RR 0.80, 95% CI 0.72 to 0.89; NNTB = 6; participants = 585; studies = 6; I² = 21%; low-certainty evidence). No study reported on the number of clinical recurrences per participant per year. We are very uncertain whether oral drug treatment compared to topical treatment increases the risk of clinical recurrence at 6 months (RR 1.66, 95% CI 0.83 to 3.31; participants = 206; studies = 3; I² = 0%; very low-certainty evidence) and reduces the risk of clinical recurrence at 12 months (RR 0.95, 95% CI 0.71 to 1.27; participants = 206; studies = 3; I² = 10%; very low-certainty evidence). No study reported on the number of clinical recurrences per participant per year. Adverse events were scarce across both treatment and control groups in both comparisons. The reporting of adverse events varied amongst studies, was generally of very low quality and could not be pooled. Overall the adverse event rate was low for both placebo and treatment arms and ranged from less than 5% to no side effects or complications. AUTHORS' CONCLUSIONS:In women with RVVC, treatment with oral or topical antifungals may reduce symptomatic clinical recurrences when compared to placebo or no treatment. We were unable to find clear differences between different treatment options (e.g. oral versus topical treatment, different doses and durations). These findings are not applicable to pregnant or immunocompromised women and women with diabetes as the studies did not include or report on them. More research is needed to determine the optimal medication, dose and frequency.

To investigate if comorbidity predicts mortality and functional impairment in middle-aged individuals with cancer (50–64 years) as compared to older individuals. A prospective cohort study. Outcomes were mortality and functional impairment at 5 years follow-up. Comorbidity was assessed using adjusted Charlson comorbidity index and polypharmacy (≥ 5 drugs) as surrogate for comorbidity. Multivariate Cox-proportional hazards and binary logit models were used to assess the risk of 5-year mortality and functional impairment respectively. We included 477 middle-aged (50–64 years) and 563 older (65 + years) individuals with cancer. The prevalence of comorbidity (at least one disease in addition to cancer) was 29% for middle-aged and 45% for older individuals, with polypharmacy observed in 15% and 31% respectively. Presence of ≥ 3 comorbidities was associated with nearly three times as high a risk of mortality in middle-aged individuals (HR 2.97, 95% CI: 1.43–6.16). In older individuals, the HR was 1.7 (95% CI 1.1–2.8). Polypharmacy was associated with a higher risk of mortality in middle-aged (HR 2.35, 95% CI 1.32–4.16) but not in older individuals (HR 1.2, 95% CI 0.9–1.8). Polypharmacy was associated with the four time the risk of functional impairment in middle-aged (OR 4.0, 95% CI 1.59–10.06) and older individuals (OR 4.4, 95% CI 1.6–11.7). This study of middle-aged and older adults with cancer shows that comorbid disease is common in younger and older individuals with cancer and are associated with inferior outcomes. Assessment and management of comorbidity should be a priority for cancer care across all age groups.

Objective: To explore the general practitioners (GP's) role in providing psychosocial care for cancer survivors through a systematic literature review. Methods: We searched MEDLINE, EMBASE, PsycINFO, and CINAHL and included the studies that complied with the predefined inclusion and exclusion criteria. At least two independent reviewers performed the quality appraisal and data extraction. Results: We included 33 (five qualitative, 19 observational, and nine intervention) studies; the majority of these studies focused on care for depression and anxiety (21/33). Cancer survivors were more likely to contact their GP for psychosocial problems compared with noncancer controls. Survivors were more likely to use antidepressants compared with controls, although 71% of survivors preferred depression treatment to be "talking therapy only." Overall, GPs and patients mostly agreed that GPs are the preferred healthcare provider to manage psychosocial problems. The major exception is a survivor's fear of recurrence-here, the oncologist was the preferred healthcare provider. Only two interventions effectively decreased depression or anxiety; these studies included patients who had a clinical indication for psychosocial care, were specifically designed for decreasing depression/anxiety, and consisted of a multidisciplinary team approach. The other interventions evaluated GP-led follow-up for cancer survivors and found that this did not impact the patients' levels of anxiety, depression, or distress neither negatively nor positively. Conclusions: Cancer survivors often prefer psychosocial care by their GP, and GPs generally consider they are well placed to provide this care. Although evidence on the effectiveness of psychosocial care by GPs is limited, an active multidisciplinary team approach seems key.

BACKGROUND:As doctors who provide care across the life-course, general practitioners (GPs) play a key role in initiating timely end-of-life discussions. Nonetheless, these discussions are often not initiated until close to death. Given the ageing of the population, GPs will be confronted with end-of-life care more often, and this needs to become a core skill for all GPs.OBJECTIVE:To describe GPs' approach to initiating end-of-life discussions.METHODS:Fifteen GPs or GP trainees from South-East Queensland, Australia, were purposively recruited to participate in a semi-structured interview. We analysed transcripts using a thematic analysis.RESULTS:GPs' approach to initiating end-of-life discussions was summarized by four themes: (1) Preparing the ground; (2) finding an entry point; (3) tailoring communication and (4) involving the family.CONCLUSIONS:Emphasis on the doctor-patient relationship; assessing patient readiness for end-of-life discussions; and sensitive information delivery is consistent with factors previously reported to be important to both GPs and patients in this context. Our findings provide a framework for GPs initiating end-of-life discussions, which must be tailored to patient and GP personality factors. Further research is required to evaluate its outcomes.

To explore the general practitioners (GP's) role in providing psychosocial care for cancer survivors through a systematic literature review.

BACKGROUND:There are no processes that routinely assess end-of-life care in Australian general practice. This study aimed to develop a data collection process which could collect observational data on end-of-life care from Australian general practitioners (GPs) via a questionnaire and clinical data from general practice software.METHODS:The data collection process was developed based on a modified Delphi study, then pilot tested with GPs through online surveys across three Australian states and data extraction from general practice software, and finally evaluated through participant interviews.RESULTS:The developed data collection process consisted of three questionnaires: Basic Practice Descriptors (32 items), Clinical Data Query (32 items) and GP-completed Questionnaire (21 items). Data extraction from general practice software was performed for 97 decedents of 10 GPs and gathered data on prescriptions, investigations and referral patterns. Reports on care of 272 decedents were provided by 63 GPs. The GP-completed Questionnaire achieved a satisfactory level of validity and reliability. Our interviews with 23 participating GPs demonstrated the feasibility and acceptability of this data collection process in Australian general practice.CONCLUSIONS:The data collection process developed and tested in this study is feasible and acceptable for Australian GPs, and comprehensively covers the major components of end-of-life care. Future studies could develop an automated data extraction tool to reduce the time and recall burden for GPs. These findings will help build a nationwide integrated information network for primary end-of-life care in Australia.

BACKGROUND:End-of-life discussions often are not initiated until close to death, even in the presence of life-limiting illness or frailty. Previous research shows that doctors may not explicitly verbalize approaching end-of-life in the foreseeable future, despite shifting their focus to comfort care. This may limit patients' opportunity to receive information and plan for the future. General Practitioners (GPs) have a key role in caring for increasing numbers of patients approaching end-of-life.OBJECTIVE:To explore GPs' thought processes when deciding whether to initiate end-of-life discussions.METHODS:A qualitative approach was used. We purposively recruited 15 GPs or GP trainees from South-East Queensland, Australia, and each participated in a semi-structured interview. Transcripts were analyzed using inductive thematic analysis.RESULTS:Australian GPs believe they have a responsibility to initiate end-of-life conversations, and identify several triggers to do so. Some also describe caution in raising this sensitive topic, related to patient, family, cultural and personal factors.CONCLUSIONS:These findings enable the development of approaches to support GPs to initiate end-of-life discussions that are cognizant both of GPs' sense of responsibility for these discussions, and factors that may contribute to caution initiating them, such as anticipated patient response, cultural considerations, societal taboos, family dynamics and personal challenges to doctors.

This is a protocol for a Cochrane Review (Intervention).The objectives are as follows:To assess the effectiveness of oral vitamin C supplements to prevent and treat acute upper respiratory tract infections in adults and children.1 Oral vitamin C supplements to prevent and treat acute upper respiratory tract infections (Protocol)

Background Receiving a cancer diagnosis can be a major life event which causes distress even years after primary treatment. Aim To examine the prevalence of distress in older patients with cancer (OPCs) up until 5 years post-diagnosis, and identify predictors present at time of diagnosis. Results are compared with reference groups of middle-aged patients with cancer (MPCs) and older patients without a cancer diagnosis (OPs). Design & setting OPCs, MPCs, and OPs participated in a longitudinal cohort study in Belgium and the Netherlands by filling in questionnaires at designated time points from 2010–2019. Method Data from 541 patients were analysed using multivariable logistic regression analyses. Results At baseline, 40% of OPCs, 37% of MPCs, and 17% of OPs reported distress. After 5 years, 35% of OPCs, 23% of MPCs, and 25% of OPs reported distress. No significant predictors for long-term distress in OPCs and OPs were found. For MPCs, it was found that baseline distress (odds ratio [OR] 2.94; 95% confidence intervals [CI] = 1.40 to 6.19) and baseline fatigue (OR 4.71; 95% CI = 1.81 to 12.31) predicted long-term distress. Conclusion Distress is an important problem for people with cancer, with peaks at different moments after diagnosis. Feelings of distress are present shortly after diagnosis but they decrease quickly for the majority of patients. In the long term, however, OPCs in particular appear to be most at risk for distress. This warrants extra attention from primary healthcare professionals, such as GPs who are often patients’ first medical contact point. More research into risk factors occurring later in an illness trajectory might shed more light on predictors for development of long-term distress.

Loneliness is an emerging and important public health concern associated with increased risk for health disorders and even mortality. Interventions targeting coping strategies might be effective in alleviating feelings of loneliness. However, the relationship between loneliness and coping strategies is not well understood. We systematically reviewed quantitative studies addressing the association between loneliness and coping. Studies were included if loneliness and coping styles were measured with a validated scale and the association between both was assessed quantitatively. We searched Medline, Embase, PsycINFO, Cochrane Library, and CINAHL databases in compliance with the predefined in- and exclusion criteria. Two independent reviewers performed the search, quality appraisal, and data extraction. Coping styles were subdivided according to problem-focused and emotion-focused coping strategies. We included twelve studies that measured the association between loneliness and coping. Half of the studies had low risk of bias (n = 6), in the remaining six the risk of bias was moderate (n = 1) or high (n = 5). All studies that showed a significant association between loneliness and coping consistently showed that problem-focused coping styles were associated with lower levels of loneliness, and emotion-focused coping styles with higher levels of loneliness. Our findings suggest that learning how to use problem-focused coping strategies could be an important aspect of interventions targeting loneliness. This should be further explored in randomized clinical trials. Trials should report changes is coping and changes in loneliness and also include multivariate models that investigate if changes in coping contributed to changes in loneliness. Furthermore, further research should explore the role of different subgroups (e.g. older people), and the role of different types of loneliness as these can affect the effectiveness of loneliness interventions.

In older adults, nutritional health is essential for good quality of life and living independently at home. Especially in cancer patients, malnutrition is common and known to complicate treatment. This study aims to evaluate the nutritional status and its associated factors in community-dwelling older adults with and without cancer.