Cardiovascular Risk Perception Research Articles

Awareness, risk perception and behavioural intention in patients with a myocardial infarction

Introduction: Background: There is limited research on the association of awareness and risk perception of cardiovascular riskfactors with behavioural intention to adhere to lifestyle targets related to risk factors such as smoking, abdominal obesity, physicalinactivity, excessive alcohol intake and inadequate fruit and vegetable intake. The association of all risk factors concurrentlyand in patients who had a myocardial infarction less than one month ago has not been previously investigated. Objective: Todescribe the association of awareness and risk perception of cardiovascular risk factors with behavioural intention in respect toaforementioned lifestyle targets in patients within one month of hospitalization for a myocardial infarction. Methods: In a cross-sectional observational study, 31 patients with a recent diagnosis of a myocardial infarction were included.Awareness, risk perception and behavioural intention were measured with a questionnaire. Data were analyzed using linearregression in which behavioural intention was divided into: risk factor not present, low and high intention. Results: The mean score for awareness was 3.9 ± 1.5 (scale range from 0 to 14) and for risk perception -0.7 ± 1.4 (scale rangefrom -3 to +3). Awareness and risk perception of cardiovascular risk factors were not associated with behavioural intention insmoking, overweight, physical inactivity and insufficient intake of fruit and vegetables. Conclusion: Patients with a myocardial infarction less than one month ago have a low awareness and low risk perception ofcardiovascular risk factors and this is not associated with behavioural intention to adhere to lifestyle targets related to risk factors.

Prevalence of atherogenic dyslipidemia in primary care patients at moderate-very high risk of cardiovascular disease. Cardiovascular risk perception

IntroductionAtherogenic dyslipidemia is an important risk factor for cardiovascular disease. We aim to determine atherogenic dyslipidemia prevalence in primary care patients at moderate-very high cardiovascular risk and its associated cardiovascular risk perception in Spain. MethodsThis cross-sectional study included 1137 primary care patients. Patients had previous cardiovascular disease, diabetes mellitus, SCORE risk ≥3, severe hypertension or dyslipidemia. Atherogenic dyslipidemia was defined as low HDL-C (<40mg/dL [males], <50mg/dL [females]) and elevated triglycerides (≥150mg/dL). A visual analog scale was used to define a perceived cardiovascular disease risk score. ResultsMean age was 63.9±9.7 years (64.6% males). The mean BMI was 29.1±4.3kg/m2, and mean waist circumference 104.2±12.7cm (males), and 97.2±14.0cm (females). 29.4% were smokers, 76.4% had hypertension, 48.0% were diabetics, 24.7% had previous myocardial infarction, and 17.8% peripheral arterial disease. European guidelines classified 83.6% at very high cardiovascular risk. Recommended HDL-C levels were achieved by 50.1% of patients and 37.3% had triglycerides in the reference range. Target LDL-C was achieved by 8.8%. The overall atherogenic dyslipidemia prevalence was 27.1% (34.1% in diabetics). This prevalence in patients achieving target LDL-C was 21.4%. Cardiovascular risk perceived by patients was 4.3/10, while primary care physicians scored 5.7/10. ConclusionsWhen LDL-C levels are controlled, atherogenic dyslipidemia is more prevalent in those patients at highest cardiovascular risk and with diabetes. This highlights the importance of intervention strategies to prevent the residual vascular risk in this population. Both patients and physicians underestimated cardiovascular risk.

Regarding: Cardiovascular Risk-factor Knowledge and Risk Perception Among HIV-infected Adults

Regarding: Cardiovascular Risk-factor Knowledge and Risk Perception Among HIV-infected Adults

Heart Health Risk Awareness and Knowledge Translation in Young South Asians

Prevalence of premature heart disease is higher among South Asians than other populations. Despite increased prevalence, South Asians under utilize Cardiac services in Fraser Health Authority. Knowledge translation to family members is unknown. Targeting younger generations of South Asians may act as away to educate and inform familymembers of risk factors and strategies for cardiovascular risk reduction. We developed and implemented a pilot assessing cardiovascular risk factor awareness and perception among young South Asians. To assess whether additional education on heart disease risk factors would encourage participants to engage in conversations of risk reduction with their family members. Development of a survey occurred with stakeholders. A health booth plan was developed to deliver surveys in multiple community settings. Analysis was completed and shared with UBC Nursing faculty and students and cardiac service programs. Participants (N 1⁄4 67) surveys were 27% male, 88% stated they knew what put them at risk for heart disease, although only 27% correctly identified less than 50% of the 10 risk factors. 72% of participants were aware that South Asian ethnicity increased their level of risk to develop heart disease. Importantly, 33% were more likely to speak with their family members about heart disease after receiving risk factor education through this pilot. Provision and screening of cardiovascular risk factor prevalence and knowledge level of younger South Asians increases personal risk factor awareness and possibly family members awareness. Larger more formal research activities and new programs need to be studied and implemented.

Cardiovascular Risk-Factor Knowledge and Risk Perception Among HIV-Infected Adults

Cardiovascular disease (CVD) has emerged as a major cause of morbidity and mortality in HIV-infected adults. Research in noninfected populations has suggested that knowledge of CVD risk factors significantly influences perceptions of risk. This cross-sectional study describes CVD risk factor knowledge and risk perception in HIV-infected adults. We recruited 130 HIV-infected adults (mean age=48years, 62% male, 56% current smokers, mean years since HIV diagnosis, 14.7). The mean CVD risk factor knowledge score was fairly high. However, controlling for age, CVD risk factor knowledge was not predictive of perceived risk [F(1, 117)=0.13, p>.05]. Estimated risk and perceived risk were weakly but significantly correlated; r(126)=.24, p=.01. HIV-infected adults are at increased risk for CVD. Despite having adequate risk-factor knowledge, CVD risk perception was inaccurate. Improving risk perception and developing CVD risk reduction interventions for this population are imperative.

Medical prescription and cardiovascular risk perception

Medical prescription and cardiovascular risk perception

Go Red for Women Cardiovascular Health–Screening Evaluation: The Dichotomy Between Awareness and Perception of Cardiovascular Risk in the Community

Cardiovascular (CV) disease is the leading cause of death in U.S. women. Although women are becoming more aware of CV disease, there remains a dichotomy between awareness and perceived risk. We sought to characterize this dichotomy in women attracted to a CV health-screening event, in order to improve strategies to reduce CV risk. During CV health events held in Rochester, Minnesota, from 2007 through 2011, 294 women underwent screening for blood chemistry, body mass index, and blood pressure. Participants also completed surveys about knowledge of CV disease, risk factors, and perceived risk. Risk level was determined from the 2011 American Heart Association Effectiveness-Based Guidelines for Women. Among participants (age, mean [standard deviation], 53 [15.3] years; white, 98%), 99% were aware that CV disease is the leading cause of death in women. Almost half (47%) perceived themselves to be at personal risk, although 65% were determined to be "at risk" and 12% to be at "high risk" according to guidelines, while 22% were uncategorized. Of the 228 participants "at risk" or "high risk," 48% and 21%, respectively, did not perceive themselves to be at any risk. Women attracted to CV health events were aware that CV disease is the leading cause of death for women. However, the magnitude of awareness did not directly translate into perception or understanding of actual personal risk. To decrease the rate of CV disease in women, continued efforts are needed to personalize the importance of, and the methods for reducing, CV risk factors.

Riesgo cardiovascular percibido por el paciente hipertenso y grado de cumplimiento terapéutico en hipertensión arterial: estudio Cumplimenhta

AimTo evaluate personal perception of the hypertense patient regarding their cardiovascular risk (CVR) severity compared to the risk established by the Primary Care (PC) physician or specialist care (SC), and to analyze the relationship between the perceived CVR and antihypertensive treatment compliance. Patients and methodsThis is a cross-sectional study in diagnosed hypertensive patients treated pharmacologically in PC and SC, using a validated questionnaire on perception of CVR and treatment compliance. The perceived CVR was compared to CVR established by doctors following the ESH/ESC-2007 guidelines, and the relationship between the perceived risk by patients and treatment compliance was analyzed. ResultsA total of 1,284 general practitioners and 370 hypertension specialists recruited consecutively 6,539 patients, mean age 63.2+10.6 years, 60.3% men. CVR established by the doctor was low in 8.1%, moderate in 32.0%, high in 38.7% and very high in 21.2%. Perceived CVR by patients was low in 25.3%, moderate in 48.0%, high in 22.7% and very high in 4.0%. Concordance between CVR established by the physicians or patients was very weak (weighted kappa 0.2867 for all physicians), particularly in those attended by specialists (kappa 0.3052 for GPS and 0.2196 for specialists). The severity of perceived risk was not related with antihypertensive treatment compliance (p=0.423). On the contrary, a significant relationship between the CVR established by doctors and treatment compliance was observed (p<0.001). However, this relationship was inverse to that expected and patients with the lowest CVR were the most compliant. ConclusionDrug-treated hypertensive patients underestimated their CVR in comparison with the CVR established by doctors following the European guidelines, particularly in those attended by specialists. No relationship was observed between perceived CVR and compliance to treatment.

Atherosclerosis Screening by Noninvasive Imaging for Cardiovascular Prevention: A Systematic Review

Conclusions: There is limited evidence concerning atherosclerosis screening, with mixed results on whether screening improves cardiovascular risk factors, no data on cardiovascular events, and only one study suggesting smoking cessation increased after identification of atherosclerosis determined through screening. Screening for atherosclerosis should be validated through clinical trials before widespread use is advocated. Summary: Possible noninvasive methods for screening for atherosclerosis include measurement of ultrasound-determined carotid intima-media thickness or carotid plaques, computed tomography imaging to assess for aortic calcification, ankle-brachial index, and flow-mediated brachial artery endothelial vasodilation. Indeed, there are measures of atherosclerosis that appear to improve the prediction of coronary heart disease events (O'Leary DH et al, N Engl J Med 1999;340:14-22; Fowkes FG et al, JAMA 2008;300:197-208). However, prediction of events does not necessarily lead to effective prevention of events (Lauer MS et al, N Engl J Med 2009;361:841-3; Young LH et al, JAMA 2009;301:1547-55). There is therefore significant controversy about the role of atherosclerosis screening in the routine clinical care of patients. The authors performed a systematic review to assess whether screening for atherosclerosis results in improvement in cardiovascular risk factors and in clinical outcomes. The authors searched MEDLINE and the Cochrane Clinical Trial Registry, without language restrictions, to identify studies to include in the review. Included studies were those assessing the impact of atherosclerosis screening with noninvasive imaging on cardiovascular risk factors, cardiovascular events, or mortality in adults without known cardiovascular disease. The authors identified four randomized control trials (RCT, n = 709) and eight nonrandomized studies comparing participants with evidence of atherosclerosis on screening with those without evidence of atherosclerosis (n = 2994). In the RCTs, screening for atherosclerosis did not improve cardiovascular risk factors but did seem to result in an increase in stop-smoking rates (18% vs 6%, P = .03). Nonrandomized studies found improvements in some intermediate outcomes such as an increased motivation to change lifestyle and increased perception of cardiovascular risk. Data, however, were conflicting and limited by lack of a randomized control group. No studies examined the impact of screening on cardiovascular events or death. Pooling of results was not possible because of extensive heterogeneity in screening methods and studied outcomes. Comment: Screening for atherosclerosis seems like a good idea. The unfortunate reality, however, is that there are no data to justify the expense and effort of noninvasive testing to screen for atherosclerosis. There are, in fact, no studies examining the impact of screening on cardiovascular events or death. It will be difficult to ever perform such a trial. A National Heart, Lung, and Blood Institute working group estimated that a trial on the impact of screening for atherosclerosis on clinical cardiovascular events would require >10,000 participants (http://www.nhlbi.nih.gov/meetings-workshops). Trials addressing the impact of noninvasive diagnostic techniques for screening for atherosclerosis are therefore not likely to be conducted anytime soon. Screening for atherosclerosis remains an expensive, likely low yield, and unproven concept.

Cardiovascular and diabetes risk perception in a Hispanic community sample.

We examined perceptions of 10-year coronary heart disease (CHD) risk or likelihood of having undiagnosed diabetes or impaired fasting glucose (IFG) with actual risk in a community sample of Hispanic adults. We conducted a survey of 183 Hispanic adults (> or =18 years) recruited at community events around Charleston, SC. Likelihood of having undiagnosed diabetes/IFG as well as 10-year CHD risk were calculated. Perceived risk was assessed with questions based on the Risk Perception Survey-Diabetes Mellitus. Over half of respondents (54.8%) underestimated their likelihood of undiagnosed diabetes/IFG and 14.8% underestimated their 10-year CHD risk. Older and overweight respondents were more likely to underestimate their likelihood of undiagnosed diabetes/IFG. Respondents with family history of diabetes were the least likely to underestimate their likelihood of current undiagnosed diabetes/IFG. Respondents with diagnosed hypertension, diabetes, high cholesterol or a family history of heart attack were more likely to underestimate their 10-year CHD risk. Men were more likely to underestimate their risk for diabetes/IFG and CHD risk. Health education to improve accurate risk perception could improve health promotion for this population.

Abstract P251: Cardiovascular Risk Perception in African Americans

Substantial racial disparities exist in heart disease. African Americans have the highest rates of cardiovascular disease (CVD). The prevalence of cardiovascular risk factors is greatest among racial minorities. African Americans are more likely to be diabetic, physically inactive, and overweight compared to whites. Additionally, African Americans participate in cardiovascular risk reduction behaviors such as diet control, exercise, and weight management at lower rates compared to individuals from other racial groups. Primary prevention of CVD through the adoption of healthy diet and physical activity behaviors is recommended to reduce the risk of developing CVD. According to health behavior theories, people must perceive themselves as susceptible to disease to adopt a preventive behavior. Few studies have examined psychological and sociocultural factors that influence cardiovascular risk perception in African Americans. As part of a randomized trial comparing the effects of integrated versus disease specific risk education in a community-based sample of African Americans, we (1) evaluated perceived risk of developing CVD and (2) identified factors having significant independent association with risk perception. The sample consisted of 199 African American adults who were on average 45.0 years (± 9.9) old. The participants were 53% male and 47% female. Approximately 23% of the participants were at intermediate or high risk for CVD. Most (83%) participants received medical care in a doctor’s office, clinic, or community health center and had a recent visit (≤ 1 year) to a doctor (84%). More than half (62%) of participants did not perceive themselves to be at increased CVD risk. In the multivariate model that controlled for age, objective risk (β=1.85, p=0.03), a family history of CVD (β=0.47, p=0.006), a recent doctor visit (β=1.90, p=0.03), and usual source of health care (β=-2.24, p=0.008) had a significant association with risk perception. Our results suggest that usual source of health care is important to perceived risk of developing CVD. This could be because provider interaction is important in appropriate CVD risk perception. Future research is needed to evaluate the content of patient-provider discussions about CVD in different settings.

Disparities between Prescribing of Secondary Prevention Therapies for Stroke and Coronary Artery Disease in General Practice

Extensive evidence exists regarding the effectiveness of secondary prevention measures in patients with cardiovascular disease. We aimed to examine the management and risk perceptions of cardiovascular events in people with established cardiovascular disease. We analyzed data on 1453 patients, ≥55 year old, with a history of cardiovascular disease, from the Australian Hypertension and Absolute Risk Study. Compared with those 533 patients with stroke/transient ischemic attack, the 743 patients with coronary artery disease were twice as likely to have been prescribed secondary prevention therapies even after adjustment for potential confounding variables (adjusted relative risks 1·85; 95% confidence interval 1·56-2·19, 42% vs. 73% for use of the combination of blood pressure-lowering, lipid-lowering and antiplatelet therapies) and to have better control of lipid and blood pressure levels. General practitioners estimated that only 27% of patients with stroke/transient ischemic attack - 38% of those with coronary artery disease and 41% of those with both conditions - were at a high risk (≥15%) of a recurrent event. Patients similarly underestimated their risk of recurrent cardiovascular events, with only 8% of stroke/transient ischemic attack, 11% of coronary and 15% of combination disease patients rating themselves at 'high' or 'very-high' risk. This study reaffirms the large treatment gap in the uptake of secondary prevention for cardiovascular disease in primary care settings, being much greater for patients with cerebral compared with cardiac cardiovascular disease. This appears to be related to differential perceptions of cardiovascular risk across different vascular territories in both patients and doctors.

Atherosclerosis Screening by Noninvasive Imaging for Cardiovascular Prevention: A Systematic Review

Noninvasive imaging of atherosclerosis is being increasingly used in clinical practice, with some experts recommending to screen all healthy adults for atherosclerosis and some jurisdictions mandating insurance coverage for atherosclerosis screening. Data on the impact of such screening have not been systematically synthesized. We aimed to assess whether atherosclerosis screening improves cardiovascular risk factors (CVRF) and clinical outcomes. This study is a systematic review. We searched MEDLINE and the Cochrane Clinical Trial Register without language restrictions. We included studies examining the impact of atherosclerosis screening with noninvasive imaging (e.g., carotid ultrasound, coronary calcification) on CVRF, cardiovascular events, or mortality in adults without cardiovascular disease. We identified four randomized controlled trials (RCT, n=709) and eight non-randomized studies comparing participants with evidence of atherosclerosis on screening to those without (n=2,994). In RCTs, atherosclerosis screening did not improve CVRF, but smoking cessation rates increased (18% vs. 6%, p=0.03) in one RCT. Non-randomized studies found improvements in several intermediate outcomes, such as increased motivation to change lifestyle and increased perception of cardiovascular risk. However, such data were conflicting and limited by the lack of a randomized control group. No studies examined the impact of screening on cardiovascular events or mortality. Heterogeneity in screening methods and studied outcomes did not permit pooling of results. Available evidence about atherosclerosis screening is limited, with mixed results on CVRF control, increased smoking cessation in one RCT, and no data on cardiovascular events. Such screening should be validated by large clinical trials before widespread use.

Statins: adherence and side-effects

AbstractMany patients either do not adhere to, or fail to persist with, long-term lipid-lowering therapy. This unfavourable medication utilisation behaviour compromises potential treatment benefit. In retrospective studies, patients aged 50–65 had the highest adherence rates, while both younger and older patients had lower rates. Patients with pre-existing cardiovascular disease adhere better than those in primary prevention. Financial barriers may impair adherence. At the individual patient level, health beliefs, perceptions of own cardiovascular risk and need for medication, concerns about side-effects and inconvenience of treatment may influence adherence. In clinical trials, regular reminders to patients have been shown to improve adherence, but each patient will require an individually tailored treatment strategy.Myopathy is the most common clinically relevant adverse effect of statins. The clinical severity of statin myopathy is highly variable, ranging from mild muscle ache to rare instances of rha...

Effects of an Office-Based Carotid Ultrasound Screening Intervention

Carotid ultrasound screening (CUS) has been recommended for cardiovascular disease risk prediction, but its effectiveness in clinical practice is unknown. The purpose of this study was to prospectively determine the effects of office-based CUS on physician decision making and patient health-related behaviors. Physicians from five nonacademic, community practices recruited patients aged ≥40 years with ≥1 cardiovascular disease risk factor. Abnormal results on CUS (AbnlCUS) were defined as carotid intima-media thickness >75th percentile or carotid plaque presence. Subjects completed questionnaires before and immediately after CUS and then 30 days later to determine self-reported behavioral changes. Odds ratios (ORs) for changes in physician management and patient health-related behaviors were determined from multivariate hierarchical logistic regression models. There were 355 subjects (mean age, 53.6 ± 7.9 years; mean number of risk factors, 2.3 ± 0.9; 58% women); 266 (74.9%) had AbnlCUS. The presence of AbnlCUS altered physicians' prescription of aspirin (P < .001) and cholesterol medications (P < .001). Immediately after CUS, subjects reported increased ability to change health-related behaviors (P= .002), regardless of their test results. Subjects with AbnlCUS reported increased cardiovascular disease risk perception (OR, 4.14; P < .001) and intentions to exercise (OR, 2.28; P= .008), make dietary changes (OR, 2.95; P < .001), and quit smoking (OR, 4.98; P= .022). After 30 days, 34% increased exercise frequency and 37% reported weight loss, but these changes were not predicted by the CUS results. AbnlCUS modestly predicted reduced dietary sodium (OR, 1.45; P= .002) and increased fiber (OR, 1.55; P= .022) intake. Finding abnormal results on CUS had major effects on physician but not patient behaviors.

Perception of cardiovascular risk following a percutaneous coronary intervention: A cross sectional study

BackgroundAn individual's perception of the risk of, and their susceptibility to, future cardiovascular events is crucial in engaging in effective secondary prevention. AimTo investigate the perception of a cardiovascular event by examining the level of agreement between individuals with CHD views of their actual and perceived risk. MethodsThis study examined the individual's perception of the risk of a subsequent cardiac event among 220 patients hospitalised for a percutaneous coronary intervention (PCI) at a metropolitan, tertiary referral hospital in Sydney, Australia. Baseline clinical and demographic characteristics were collected, and actual risk (Personal Risk Score) calculated based on the presence or absence of nine cardiovascular risk factors: diabetes, hypertension, high cholesterol, cigarette smoking, previous history of CHD, family history of CHD, depression, overweight or obesity, and physical inactivity. Perception of risk was determined using an investigator-developed 4-item, 11-point Likert scale instrument (Perceived Heart Risk Questionnaire – PHRQ) which measured two dimensions of health threat: perceived seriousness, and perceived susceptibility. The correlation between the Personal Risk Score and the PHRQ was assessed using the Pearson product-moment correlation coefficient. ResultsThe calculated mean Personal Risk Score was 4.63±1.71 and the PHRQ was 25.5±7.04. The correlation between the Personal Risk Score (actual risk) and the PHRQ (perceived risk) was r=0.26 (p<0.01). ConclusionsThe weak relationship between actual and perceived risk is of concern, particularly in a population at higher risk for future cardiovascular events. Implementing strategies to personalise risk should be explored to improve the accuracy of risk perception, and facilitate tailoring of behaviour change strategies.

Gender disparities in the assessment and management of cardiovascular risk in primary care: the AusHEART study

Studies indicate ongoing gender-based differences in the prevention, detection and management of cardiovascular disease. The aims of this study were to determine whether there are differences in general practitioners' (GPs') perceptions of a patient's cardiovascular risk compared with the patient's estimated risk and in the patient's subsequent medical management according to patient sex. The Australian Hypertension and Absolute Risk Study (AusHEART) was a nationally representative, cluster-stratified, cross-sectional survey among 322 GPs. Each GP was asked to collect data on cardiovascular disease risk factors and their management in 15-20 consecutive patients (age ≥55 years) who presented between April and June, 2008. They were also asked to estimate each patient's absolute risk of a cardiovascular event in the next five years. The main outcomes were the Adjusted Framingham risk, GP estimated risk and proportion of patients receiving blood pressure-lowering, statin and antiplatelet therapy. A total of 5293 patients were recruited to the study, of whom 2968 (56%) were women. Among patients without established cardiovascular disease, the level of agreement between the GP estimated risk and the Adjusted Framingham risk was poor (<50%) and was similarly so for men (kappa coefficient 0.18; 95% confidence interval (CI) 0.14-0.21) and women (0.19; 95% CI 0.16-0.22; P homogeneity = 0.57). For patients with established cardiovascular disease, however, women were more likely to be assigned by the GP to a lower risk category (66% vs. 54%, P < 0.001) and less likely to be prescribed combination (blood pressure-lowering, statin and antiplatelet) (44% vs. 56%, P < 0.001) therapy compared with men, even after adjusting for patient age. Cardiovascular risk is underrecognized and undertreated in Australian primary care patients, with women apparently disproportionately affected. These findings underscore the importance of initiatives to raise awareness of cardiovascular disease in women.

Cardiovascular risk perception and evidence–practice gaps in Australian general practice

Cardiovascular risk perception and evidence–practice gaps in Australian general practice

Cardiovascular risk perception and evidence–practice gaps in Australian general practice

Cardiovascular risk perception and evidence–practice gaps in Australian general practice

Cardiovascular risk perception and evidence–practice gaps in Australian general practice

Medical Journal of AustraliaVolume 193, Issue 2 p. 127-128 In Clinical Practice Cardiovascular risk perception and evidence–practice gaps in Australian general practice Peter J Radford, Corresponding Author Peter J Radford General Practitioner drdog@iinet.net.au Benalla, VIC.Correspondence: drdog@iinet.net.auSearch for more papers by this author Peter J Radford, Corresponding Author Peter J Radford General Practitioner drdog@iinet.net.au Benalla, VIC.Correspondence: drdog@iinet.net.auSearch for more papers by this author First published: 19 July 2010 https://doi.org/10.5694/j.1326-5377.2010.tb03823.xCitations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume193, Issue2General practice issueJuly 2010Pages 127-128 RelatedInformation