General Practice Patients Research Articles

Insulin treatment for diabetes

The first use of insulin in 1922 began a new era in the management and survival of patients with type 1 diabetes. Before 1922, patients with this condition were placed on a starvation diet and survived only a few months. Nearly a century later, insulin remains the dominant treatment for type 1 diabetes, is used in gestational diabetes and increasingly in type 2 diabetes. This article focuses on insulin treatment for adult diabetic patients in general practice. It will explore the effect of insulin and the role it has in diabetes, the preparations available, recommended regimens and some challenges with insulin treatment.

Impact of an extended audit on identifying heart failure patients in general practice: baseline results of the OSCAR-HF pilot study.

AimsIdentifying heart failure (HF) patients in general practice is challenging, and little is known about the current quality of care. We implemented an extended audit from the electronic health records (EHRs) of general practitioners (GPs) to identify HF patients and investigate patient characteristics and quality of care.Methods and resultsThis study describes the baseline results of the OSCAR‐HF pilot study in eight general practices (51 GPs) in Flanders, Belgium. This prospective trial ran for 6 months. Interventions included an extended audit, an N‐terminal pro‐B‐type natriuretic peptide point‐of‐care test, and assistance of a specialist HF nurse. The extended audit searched on risk factors for HF, HF symptoms, signs, and medication in the GPs' EHR to generate a list of possible HF patients. GPs determined which patients had HF. Those HF patients constituted the OSCAR‐HF study population. Each patient file was manually revised to extract biomarker measurements, echocardiography data, and quality indicators. An independent panel of experts assessed the validity of GPs' HF diagnoses. Feedback about the validity of the HF diagnosis was given to the GP. Out of 18 011 patients ≥ 40 years, we identified 310 patients with a registered HF diagnosis before the study start (HF prevalence: 1.7%). The extended audit led to a 74% increase in identified HF patients (n = 538, HF prevalence: 3.0%) with a mean age of 79 ± 11 years. The prevalence of HF with reduced ejection fraction (HFrEF) was 20% (n = 110). A high proportion of patients underwent echocardiography in the past 5 years (86%, n = 462). Natriuretic peptides were rarely available in patients' files (19%, n = 100). Medical specialists should improve communication about the HF diagnosis because a specialist diagnosis was present in only 225 patients (42%) while 67% (n = 359) of the HF diagnoses were judged objectified by a panel of experts. Assigning a diagnosis of HF was particularly difficult in HF patients with preserved EF (HFpEF). HFrEF treatment rates with renin–angiotensin–aldosterone system blockers (84%, n = 92) and beta‐blockers (86%, n = 94) were very good; however, target doses were hardly reached (34% and 14%, respectively).ConclusionsThis study highlighted the need to improve case finding for HF in general practice and showed that an extended audit in the GPs' EHR was a successful strategy to do so. To improve the quality of HF care in general practice, specific strategies are needed to diagnose HFpEF and to reach target doses of disease‐modifying drugs in HFrEF patients.

Clinician and Patient Factors Influencing Treatment Decisions: Ethnographic Study of Antibiotic Prescribing and Operative Procedures in Out-of-Hours and General Dental Practices.

Operative treatment is indicated for most toothache/dental abscesses, yet antibiotics instead of procedures are often prescribed. This ethnographic study aimed to identify clinician and patient factors influencing urgent dental care for adults during actual appointments; and to identify elements sensitive to context. Appointments were observed in out-of-hours and general dental practices. Follow-up interviews took place with dentists, dental nurses, and patients. Dentist and patient factors were identified through thematic analysis of observation records and appointment/interview transcripts. Dentist factors were based on a published list of factors influencing antibiotic prescribing for adults with acute conditions across primary health care and presented within the Capability-Opportunity-Motivation-Behaviour model. Contextually sensitive elements were revealed by comparing the factors between settings. In total, thirty-one dentist factors and nineteen patient factors were identified. Beliefs about antibiotics, goals for the appointment and access to dental services were important for both dentists and patients. Dentist factors included beliefs about the lifetime impact of urgent dental procedures on patients. Patient factors included their communication and negotiation skills. Contextual elements included dentists’ concerns about inflicting pain on regular patients in general dental practice; and patients’ difficulties accessing care to complete temporary treatment provided out of hours. This improved understanding of factors influencing shared decisions about treatments presents significant opportunity for new, evidence-based, contextually sensitive antibiotic stewardship interventions.

Meeting demand for opioid dependency in an Inner London borough

This paper is looking at the development of the Benzodiazepine and Opiate Withdrawal Service (BOWS) in the borough in Inner London to implement a model that would treat patients effectively in GP practices. It is to illustrate what can be achieved with experienced nurse prescribers in treating an emerging group of patients in primary care. Often patients are aware of their dependency on opiate medications and do want to reduce and come off their medications. This paper describes the BOWS service and its approach, illustrating what can be possible, in terms of treatment for patients in general practice. It also shows what can be designed in NHS services to address the growing issue of dependency on prescribed drugs and argues that services having experience in addictive behaviours can play a very large role in achieving this.

Exploring the health and service utilisation of general practice patients with a history of adverse childhood experiences (ACEs): an observational study using electronic health records

ObjectivesTo examine the relationships between adverse childhood experiences (ACEs), chronic health and health service utilisation among a sample of general practice patients.DesignCross-sectional observational study using anonymised data from electronic health...

The Impact of the 2019 European Guideline for Cardiovascular Risk Management: A Cross-Sectional Study in General Practice.

The aim of this study was to assess the impact of the 2019 published European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guideline on cardiovascular (CV) risk management compared with its predecessor from 2016 in a cohort in general practice. We performed a cross-sectional retrospective study with data from electronic medical records. The study cohort included 103,351 patients with known CV risk. We assessed changes in CV risk classification and low-density lipoprotein cholesterol (LDL-C) target values, the impact on LDL-C achievement rates, and the current lipid-lowering treatments. Under the 2019 ESC guideline, CV risk categories changed in 27.5% of patients, LDL-C target levels decreased in 71.4% of patients, and LDL-C target achievement rate dropped from 31.1% to 16.5%. Among non-achievers according to the 2019 guideline, 52.2% lacked lipid-lowering drugs entirely, and 41.5% had conventional drugs at a submaximal intensity. Of patients in the high-risk and very high-risk categories, at least 5% failed to achieve the LDL-C target level despite treatment at maximal intensity with conventional lipid-lowering drugs, making them eligible for PCSK-9 inhibitors. In conclusion, the 2019 ESC/EAS guideline lowered LDL-C target values for the majority of patients in general practice and halved LDL-C target achievement rates. There is still a large undeveloped potential to lower CV risk by introducing conventional lipid-lowering drugs, particularly in patients at high or very high CV risk. A substantial proportion of the patients can only achieve their LDL-C targets using PCSK-9 inhibitors, which would currently require an at least 10-fold increase in prescribing of these drugs.

\u2018Very brief advice\u2019 (VBA) on smoking in family practice: a qualitative evaluation of the tobacco user\u2019s perspective

BackgroundVery Brief Advice on smoking (VBA) is an evidence-based intervention designed to increase quit attempts among patients who smoke. VBA has been widely disseminated in general practice settings in the United Kingdom, however its transferability to Southern European settings is not well established. This study sought to document the perspectives of Greek general practice patients in terms of the acceptability and satisfaction with receiving VBA from their general practitioner (GP) and its influence on patients’ motivation to make a quit attempt. We also examine patient identified barriers and facilitators to acting on VBA.MethodsSemi-structured interviews were conducted with 50 patients who reported current tobacco use recruited from five general practices in Crete, Greece. All patients received VBA from their GP and interviews were conducted immediately after the GP appointment. Thematic analysis was used to analyze data.ResultsThe majority of patients were satisfied with the VBA intervention. Approximately one quarter of patients reported they were motivated to make an attempt to quit smoking after receiving VBA from their GP. Patients identified a clear preference for VBA to be delivered in a supportive manner, which communicated genuine concern versus fear-based approaches. Patients with an existing smoking-related illness were more likely to report plans to act on their GP’s VBA. Patients not ready to quit smoking indicated they would be likely to seek the support of their GP for future quit attempts as a result of VBA. Many patients reported low self-efficacy with quitting and apprehension about available quit smoking supports.ConclusionsVBA was positively received by the majority of smokers interviewed. Participating patients confirmed the motivational role of advice when delivered in a supportive and caring manner. Personal health status, beliefs about quit smoking supports, and low self-efficacy appear to influence patient’s motivation to make an aided quit attempt.

General practice patients starting treatment for substance use problems: observations from two data sources across levels of care

BackgroundIn Belgium, the incidence of treatment episodes for substance use problems is monitored by the Network of Sentinel General Practices (SGP), and at higher, specialist care levels by the Treatment Demand Indicator (TDI) surveillance. Using both data sources, we examine 1) how patients starting specialist treatment for substance use problems on referral by their GP compare to those that were referred by non-GP caregivers; 2) how patients starting GP treatment for substance use problems without receiving concurrent specialist treatment compare to those who did.MethodsBoth surveillances are based on the TDI protocol for reporting data to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) on individuals starting treatment as a result of their substance use. Data from 2016 and 2017 were examined using 95% confidence intervals and multivariate logistic regression.ResultsAccording to TDI-data (n = 16,543), determinants of being referred by a GP (versus by a non-GP caregiver) for specialist treatment were age ≥ median (OR 1.25; 95% CI 1.13–1.38), education ≥ secondary level (OR 1.27; 95% CI 1.15–1.41), recent employment (OR 1.71; 1.56–1.88), recent stable accommodation (3.62; 95% CI 3.08–4.26), first treatment episode (OR 1.72; 95% CI 1.57–1.87), recent daily primary substance use (OR 1.46; 95% CI 1.33–1.59) and mono substance use (OR 1.23; 95% CI 1.04–1.48). Type of substance use was a significant determinant with higher odds of using pharmaceuticals (and alcohol) (OR 1.24; 95% CI 1.04–1.48), and lower odds of using cannabis only/primarily (OR 0.73; 95% CI 0.62–0.86), with reference to street drugs minus cannabis only/primarily. According to SGP data (n = 314), determinants of starting GP treatment without concurrent specialist treatment were recent employment (OR 2.58; 95% CI 1.36–4.91), first treatment episode (OR 2.78; 95% CI 1.39–5.55) and living in the Brussels or Walloon region (OR 1.97; 95% CI 1.06–3.66).ConclusionsThis study provides a useful insight into the general practice population treated for substance use problems. It shows that both surveillances consistently found a relatively favourable profile of general practice patients with substance use problems.

Quality use of medicines in patients with chronic kidney disease

BackgroundChronic kidney disease (CKD) affects drug elimination and patients with CKD require appropriate adjustment of renally cleared medications to ensure safe and effective pharmacotherapy. The main objective of this study was to determine the extent of potentially inappropriate prescribing (PIP; defined as the use of a contraindicated medication or inappropriately high dose according to the kidney function) of renally-cleared medications commonly prescribed in Australian primary care, based on two measures of kidney function. A secondary aim was to assess agreement between the two measures.MethodsRetrospective analysis of routinely collected de-identified Australian general practice patient data (NPS MedicineWise MedicineInsight from January 1, 2013, to June 1, 2016; collected from 329 general practices). All adults (aged ≥18 years) with CKD presenting to general practices across Australia were included in the analysis. Patients were considered to have CKD if they had two or more estimated glomerular filtration rate (eGFR) recorded values < 60 mL/min/1.73m2, and/or two urinary albumin/creatinine ratios ≥3.5 mg/mmol in females (≥2.5 mg/mmol in males) at least 90 days apart. PIP was assessed for 49 commonly prescribed medications using the Cockcroft-Gault (CG) equation/eGFR as per the instructions in the Australian Medicines Handbook.ResultsA total of 48,731 patients met the Kidney Health Australia (KHA) definition for CKD and had prescriptions recorded within 90 days of measuring serum creatinine (SCr)/estimated glomerular filtration rate (eGFR). Overall, 28,729 patients were prescribed one or more of the 49 medications of interest. Approximately 35% (n = 9926) of these patients had at least one PIP based on either the Cockcroft-Gault (CG) equation or eGFR (CKD-EPI; CKD-Epidemiology Collaboration Equation). There was good agreement between CG and eGFR while determining the appropriateness of medications, with approximately 97% of the medications classified as appropriate by eGFR also being considered appropriate by the CG equation.ConclusionThis study highlights that PIP commonly occurs in primary care patients with CKD and the need for further research to understand why and how this can be minimised. The findings also show that the eGFR provides clinicians a potential alternative to the CG formula when estimating kidney function to guide drug appropriateness and dosing.

Increased Risk of COVID-19-Related Deaths among General Practitioners in Italy.

To date, data on COVID-19-related death cases among physicians from different medical specialties are incomplete and scattered. In Italy, available data highlight that general practitioners (GPs) are, apparently, the most heavily affected group. Indeed, they currently represent 44.1% of the total COVID-19 related death cases occurred among physicians, whereas they constitute about 15% of the total number of doctors. This high proportion is most likely the consequence of a work-related contagion happening especially during the first weeks of the epidemic, and persisting also in the following weeks, after the national lockdown. There are various reasons for these higher contagion rates: GPs perform a lot of medical examinations daily, usually in close contact with patients. Especially at the beginning of the epidemic, GPs might have had scant information on the specific safety procedures for the prevention of SARS-CoV-2 transmission (e.g., there was limited knowledge on the possibility of contagions deriving from asymptomatic patients) and, moreover, the availability of personal protective equipment was insufficient. Furthermore, the risk of infection is highly increased by the virus’ characteristics, like its survival for several hours/days on different surfaces and its persistence in the air after an aerosolization process, with possibilities to be transmitted over distances longer than two meters. Following these observations, and considering the high cost in term of GPs’ lives, the COVID-19 pandemic will probably revolutionize the approach to patients in general practice. Clear and effective guidelines are absolutely and urgently needed for the refinement of adequate measures to prevent SARS-CoV-2 infections among GPs.

Antibiotic resistance of uropathogenic Escherichia coli and ESBL prevalence in general practice patients over 10 years.

Bacterial susceptibility to antibiotics changes over time. Knowledge of the susceptibility is important for antibiotic treatment guidelines in general practices. To determine the antibiotic-susceptibility of E. coli from uncomplicated UTI among women in general practices in the Netherlands and to compare the results with those collected in 2004 and 2009. Urine samples were collected from women with symptoms of uncomplicated UTI, in 30 sentinel GP practices of the Nivel Primary Care database. Patient characteristics, E. coli susceptibility and ESBL prevalence were analysed. In total, 689 samples were collected. E. coli was the most isolated uropathogen (83%). Antibiotic susceptibility was stable over time except for ciprofloxacin (96%, 97% and 94% in 2004, 2009 and 2014, respectively; P<0.05). The susceptibility to co-amoxiclav was 88%, 87% and 92% in 2004, 2009 and 2014, respectively. The prevalence of ESBL producing E. coli increased from 0.1% in 2004, to 2.2% in 2014 (P<0.05). Susceptibility for co-trimoxazole was the highest in the West (88%) and the lowest in the North (72%, P = 0.021). Ciprofloxacin susceptibility was related to antibiotic use in the past 3 months (97% no use versus 90% use, P = 0.002) and those aged >70 years (P = 0.005). In 2014, prescription of fosfomycin increased compared to 2009 (14.3% versus 5.6%) at the expense of co-amoxiclav, co-trimoxazole and ciprofloxacin (P<0.05). The antibiotic susceptibility percentages to the agents tested were stable over the 10-year period, except for ciprofloxacin as was the prevalence of ESBL producing E. coli. Surveillance with regular intervals is warranted.

Identifying Palliative Patients in General Practice: Focusing on the Place of Death and the Vital Role of Specialized Home Palliative Care: An Observational Study.

Objectives: Specialist palliative care was introduced into the German health care system for patients at the end of life. The primary objective of this study was to assess whether the provision of specialist home palliative care (SHPC) for outpatients increased the likelihood of patients dying at home. Methods: We studied data collected in 2015 from a German statutory health insurance company covering 3.872 million people. We evaluated how many patients were identified as needing palliative care and whether these patients were able to stay at home until death. The data were ascertained from general practices in Baden-Wuerttemberg, a part of Germany. Palliative care patients were identified using the International Classification of Diseases (ICD)-10 code Z51.5 or the assigned medical billing code of the German fee schedule. Patients receiving care from an SHPC team were identified using the billing codes 01425 or 01426. Adjusted odds ratios were calculated for the place of death with multivariable logistic regression. Results: We found 21,190 (0.55%) palliative patients in the whole population. Of these, 19,507 (92.05%) patients received general palliative care and 1683 (7.95%) patients received specialist palliative care. Mortality rate across all patients was 1.08% (41,800) and mortality rate of palliative patients was 44.08% (9494). In total, 19,833 (47.5%) of the general population died in hospitals, as opposed to only 2208 (23.2%) among palliative patients. Further analysis revealed that of those palliative patients receiving SHPC, 160 (13.3%) died in hospitals as opposed to 2048 (24.7%) of those receiving general care. The probability of dying at home increases already with the label "palliative patient" and gets stronger if care is provided by a specialist palliative care team. Conclusion: Most palliative patients are able to die at home. Palliative care teams are responsible for a small part of these patients. Despite the high symptom burden in this group, most are able to die at home.

Duration of carriage of multidrug resistant Enterobacterales in discharged hospital and general practice patients and factors associated with clearance

SummaryObjectivesDutch guidelines recommend contact precautions in patients with multidrug resistant microorganisms cultured during the previous 12 months. To evaluate this policy, duration of carriage of multidrug resistant Enterobacterales was assessed among discharged hospital patients and patients attending their general practitioner (GP). Additionally, we assessed factors associated with clearance.MethodsFrom January 2013 until May 2016, rectal or faecal samples accompanied by questionnaires on patient characteristics were obtained at time of study inclusion and 3, 6 and 12 months later, in 72 patients with multidrug resistant Enterobacterales. Clearance was defined as one or more negative cultures without a subsequent positive culture at 12 months after study inclusion. The percentage of clearance, intermittent carriage and persistence was determined and associated factors were assessed by logistic regression analysis.ResultsClearance was found in 31 patients (43.1% [95%CI: 32.3–54.6]) of which 23 patients had two or more subsequent negative cultures. Twelve patients were classified as intermittent carriers (16.7% [95%CI: 9.8–26.9]) and 29 patients (40.3% [95% CI: 29.7–51.8]) as persistent carriers. Of the intermittent carriers, the majority (n=9) had two negative cultures during the study period. There was no difference in clearance between discharged hospitalized patients and GP patients. The only factor associated with clearance at 12 months in both univariable and multivariable analyses was not traveling to a foreign country (OR=3.5 [95%CI: 1.0–12.4]).ConclusionActive screening for clearance of multidrug resistant Enterobacterales in patients within the health care setting is probably not beneficial due to high levels of intermittent and persistent carriage.

Care in Chronic Diseases and in "Frail" Patients in General Practice

The world of chronicity is an area in progressive growth that involves a considerable commitment of resources, requiring continuity of assistance for long periods of time and a strong integration of health services with social ones and those requiring residential and territorial services often not sufficiently designed and developed. The fundamental aim of the treatment of chronic systems is to keep as much as possible the patient at home and prevent or reduce the risk of institutionalization. GP could put their expertise to good use in the Complex of Primary Care Units and Territorial Functional Aggregations, reducing the costs of the health service.

Advance care plans for patients in general practice

The coronavirus pandemic has led national leaders to encourage providers to put advance care plans in place for older people, those who are frail and people with other serious conditions. We examine why this is important and how this is addressed

Supporting general practitioners and practice staff after a patient suicide: A proposal for the development of a guideline for general practice.

Managing the completed suicide of a patient in general practice has long been a taboo and neglected subject. Doctors and staff are too frequently unprepared for the crisis and its sequelae. The wellbeing of the doctor, practice staff and bereaved family are often neglected, with detrimental consequences. The aim of this article is to develop aguideline for awhole-of-practice strategy to support general practitioners and practices through the immediate aftermath of a patient suicide, with a view to improving outcomes for the doctor, practice staff and bereaved family; and to offer this guideline for further research anddevelopment, withaview to it leading to a nationalguideline. In this article, the authors outline the background of the guideline and the difficulties and limitations in its development. Suggestions for future research are offered, along with its potential contribution to patient care and suicide prevention in the future.

Patients’ views on involving general practice in bowel cancer screening: a South Australian focus group study

ObjectivesTo explore patients’ experiences of bowel cancer screening and its promotion, and perspectives on possible input from general practice for improving screening rates.DesignQualitative focus group study underpinned by a phenomenological...

Fitter, Better, Sooner: helping your patients in general practice recover more quickly from surgery.

Having an operation is a major event in a patient’s life. Many will have had limited previous exposure to hospitals. There is much patients can do to improve their physical and mental health prior to surgery that can have a significant impact on their recovery and long-term health. Understanding the steps they can take can empower patients to make lasting changes. Fitter, Better, Sooner is a toolkit aimed at helping patients to prepare physically and psychologically for surgery (Figure 1). It was produced by the Royal College of Anaesthetists (RCoA), with representatives from the Royal College of General Practitioners (RCGP) and the Royal College of Surgeons (RCS), and with patient representatives playing key roles on the working group, reflecting the importance of multidisciplinary input for optimal perioperative care. The resources have been endorsed by both the RCGP and RCS, and have been awarded ‘highly commended’ in the BMA Patient Information Awards 2019. Figure 1. Fitter, Better, Sooner patient information resources. https://www.rcoa.ac.uk/patient-information/ preparing-surgery-fitter-better-sooner. © Royal College of Anaesthetists. The toolkit is intended for patients who are awaiting, or considering, surgery. It introduces the many ways in which they can optimise their health, lifestyle, and activity levels to maximise their chances of a good recovery, free of complications. It …

Nonverbal communication between registered nurses and patients during chronic disease management consultations: Observations from general practice.

This study explores nonverbal communication behaviours between general practice nurses and patients during chronic disease consultations. Nonverbal communication is an important aspect of nurse-patient lifestyle risk reduction conversations. Despite the growing role of general practice nurses in lifestyle risk modification when managing chronic disease, few studies have investigated how this communication occurs. Observational study within a concurrent mixed methods project. Thirty-six consultations by 14 general practice nurses were video-recorded between August 2017 and March 2018. Video analysis used the Nonverbal Accommodation Analysis System. TheSTROBE checklist was used to guide this paper. Joint convergence of nurse-patient behaviours such as laughing, smiling and eye contact was most common (44%; n=157). Patient-nurse eye contact time decreased significantly across the consultation, while nurse gesturing increased significantly. No significant relationship between consultation length and convergent to divergent behaviour categorisation or nurse-computer use across the consultation was found. The high levels of convergent behaviours are promising for person-centred care. However, scope exists to enhance nonverbal interactions around lifestyle risk reduction. Supporting nurses with skills and improved environments for lifestyle risk communication has potential to improve therapeutic relationships and patient outcomes. These results indicate that nurses support patients through nonverbal interactions during conversations of lifestyle risk reduction. However, there are opportunities to improve this practice for future interventions.

Prevalence and distribution of psychological diagnoses and related frequency of consultations in Norwegian urban general practice

Objective: To investigate the prevalence and distribution of psychological diagnoses made by general practitioners (GPs) in urban general practice and the related frequency of consultations during 12 consecutive months in Norwegian general practice.Design: A cross-sectional study with data extracted from 16,845 electronic patient records in 35 urban GP practicesSetting: Six GP group practices in Groruddalen, Norway.Subjects: All patients aged 16–65 with a registered contact with a GP during 12 months in 2015.Main outcome measures: Frequency and distribution of psychological diagnoses made by GPs, and the number of patients’ consultations.Results: GPs made a psychological diagnosis in 18.8% of the patients. The main diagnostic categories were depression symptoms or disorder, acute stress reaction, anxiety symptoms or disorder and sleep disorder, accounting for 67.1% of all psychological diagnoses given. The mean number of consultations for all patients was 4.09 (95% CI: 4.03, 4.14). The mean number of consultations for patients with a psychological diagnosis was 6.40 (95% CI: 6.22, 6.58) compared to 3.55 (95% CI 3.50, 3.51) (p<0.01) for patients without such a diagnosis. Seven percent of the diagnostic variation was due to differences among GPs.Conclusions: Psychological diagnoses are frequent in urban general practice, but they are covered using rather few diagnostic categories. Patients with psychological diagnoses had a significantly higher mean number of GP consultations regardless of age and sex.Implications: The knowledge of the burden of psychological health problems in general practice must be strengthened to define evidence-based approaches for detecting, diagnosing and treating mental disorders in the general practice population.Key PointsEighteen percent of patients aged 16–65 in our study of patients in urban general practice received one or more psychological diagnoses in 12 months.Depression was the most common diagnosis; followed by acute stress reaction, anxiety and sleep disturbance.Patients with psychological diagnoses had a significantly higher mean number of consultations compared to patients without such diagnoses regardless of age and sex.