Journal de médecine générale

Leishmaniasis is an endemic parasitic disease in 88 countries. It is widely distributed throughout the world, caused by vector-borne, obligate, intracellular hemoflagellates of the genus leishmania. The parasite continues its life cycle transforming to promastigote in the midgut of the sandfly vector and is transmitted to the human host in the form of promastigote through the bite of the sandfly. Other less encountered forms of transmissionare because of a laboratory accident, direct person-to-person transmission, organ transplant and blood transfusion. There is evidence that leishmaniasis may be transmitted either in utero or during the peripartum period. The promastigote form is considered the primary organism of disease transmission between the vector and the host. By not having a chance to continue its life cycle and transform into promastigote within the vector sandfly, and considering the many different routes of transmission other than the sandfly bites, it is reasonable to assume an alternative possible existence of the promastigote form of the parasite in the infected lesion of cutaneous leishmaniasis in human host. The information presented below indicates that a real transformation of amastigote to promastigote form occurs within the human host cutaneous lesion in the extracellular fluid after the macrophage membrane eruption and the amastigote release. New techniques are recommended for future studies to confirm these findings including realtime Polymerase chain reaction (PCR) and applying the immunohistochemistry techniques using novel monoclonal antibody (mAb) against the parasite flagellate (promastigote form) cell wall component.

With the advent of ubiquitous smartphone devices, health apps have become common, allowing the delivery of services and health messages to target populations, right in their pockets. Therefore, the use of these devices has potential to move information dissemination beyond just face-to-face consultations. This research highlights the lessons learned from the Safe-D (Safe vitamin D) case study to develop an Apple and Android app to safely improve vitamin D status in young women. The Safe-D App aims to assist individuals in a more personal manner, through self-monitoring and personalized relevant health messages that are dependent on the individual’s monitored behavior. This paper will provide guidelines for message construction, along with recommendations to deliver targeted messages.

Objective: This study tried to explore gender differences in Lower urinary tract symptoms (LUTS) and disparities in adaptation strategies used to cope with LUTS. Materials and Methods: From July 2013 to December 2013, 184 consecutive patients who came to a tertiary center seeking medical treatment for LUTS including stress urinary incontinence (SUI), overactive bladder (OAB), and mixed urinary incontinence (MUI) were recruited in this study. OABSS, IPSS and UDI-6 were used to evaluate severities of these symptoms and IIQ-7 was used to measure the impact of these three symptoms on the quality of life. Patients’ coping strategies were also compared to evaluate gender differences. Results: In total, 184 patients (81 men and 103 women) were recruited into this study. The LUTS between genders were significant. Women had significantly more SUI and MUI than that of men, but men had significantly more OAB. The LUTS in men seemed to have less impact on quality of life than in women. Preventive toileting use before going out, restricting fluid intake, or seeking treatment at primary care clinics were adaptive strategies used by both genders. However, one-third of the women used incontinence pads or performed pelvic floor exercises to prevent urine leakage and nearly one-fourth of the women avoided contact with cold water or performed urge strategies to control the urge to void. Conclusions: Gender differences in LUTS are significant. Similar LUTS also result in different impact on men and women. Women used more coping strategies than men to handle their bothersome LUTS.

Background: Midwifery led care (MLC) is a model of care in which perinatal care is provided to women throughout different phases of childbirth by a midwife. Objective: This paper aims to provide a literature review on MLC. Methods: A variety of databases and reports were considered to do the literature review on MLC. The search was limited from 1991 to 2011 by using keywords. A total of 50 articles were critically appraised for this review. Findings: The main theme that emerged was women’s satisfaction with MLC. Satisfaction was integrated with midwife’s presence throughout childbirth, experience to enhance normality in childbirth, cost-effectiveness of MLC, and facilitation of women’s choice and control during labor. Conclusion: The review concludes that MLC is women-friendly as it considers and respects women’s needs holistically during childbirth.

Sri Lanka is known for its commendable healthcare indices in the region. Now the country is going through a transition of economic development after the devastation as a result of a 30-year war and the natural disaster of a tsunami in 2004. At the same time, there is a demographic and epidemiological transition. The proportion of older population is increasing with a simultaneous increase in non-communicable diseases. The country is achieving its millennium development goals through improving neonatal mortality, infant mortality maternal mortality, vaccination coverage and life expectancy, mainly because of the maternal and child health care services delivered to the public on a well-structured target population. However the target population for delivery of ambulatory care has not been strictly defined. Freedom of visiting doctors without referrals in a background of not having a target population has created many problems. Optimum utilization of expert services has been hampered due to overcrowding and maldistribution of service demand. Commercialization of healthcare has extended to inappropriate importation of drugs and opening up of pharmacies. Out-of-pocket spending for out-patient care has escalated over the years at a significant rate probably contributed to by individual investments in health promotion or NCD prevention. Lack of responsibility to a target population has undermined the doctor patient relationship that is probably contributing to some of the prevailing undesirable behavior patterns of healthcare professionals. Organizational reforms including recognizing target populations and promoting patient centered approaches in establishments and teaching and training on competencies for family physicians, starting from the undergraduate curriculum, would be a worthy investment in the future health of the nation.

Parental mental illness is a powerful risk factor, with a potential of serious impact for the children. Mental health problems are often transmitted from one generation to the next. Parental mental illness is however considered to be a malleable risk-factor, which means there are measures that can be taken to counteract the risk. Nevertheless, transferring this knowledge to the field of parental mental illness has been very difficult. The aim of the current study was to explore the relationship between knowledge and attitudes towards a child perspective in adult mental health services and actual clinical practice. The aim was furthermore to investigate which factors are hindering or promoting the translation of new knowledge to the field of practice. In the present study results will be interpreted in light of the theory of reasoned action.

Pressure ulcers (PU) are a common medical complication in the frail elderly. Due to the increase of the elderly population and accrued accompanying comorbidities, there is a higher prevalence of pressure ulcers. These induce suffering and worsening in quality of life and prolong hospitalization. Pressure ulcers are a burden on the medical services and increase their cost substantially. Systemic factors such as aging of the skin, functional impairment, chronic diseases, malnutrition and infection contribute to the appearance of the ulcers and activate development. Low BMI, anemia, low protein and albumin are predisposing factors, as well as serious complications of pressure ulcers interfere with the cure. Prevention of pressure ulcers should be started by the primary care givers through education of the patient and family concerning the external factors as pressure relieving devices, especially mattresses and cushions, position changes, lubrication of the skin and adequate calorie intake for the patient. Attention becomes directed to changes of the skin especially at the location of bone prominences exposed to pressure. A zero-tolerance policy is necessary by the primary physician and the nurse, concerning pressure ulcers. The treating physician familiar with the diseases of the immobile patients and the systemic factors leading to pressure ulcers should apply all available preventive measures.

The provision of brief intervention (BI) for alcohol misuse in community pharmacies appears to be feasible, although little has been done in determining its impact. This research aims to model pharmacists’ delivered screening, BI and costs per additional risky drinker reducing alcohol consumption relative to current practice in rural Australia. A decision model was developed to assess costs and changes in outcomes from pharmacist-delivered screening and BI on alcohol consumption in 10 rural communities in New South Wales, Australia. Nine different scenarios were utilised to test the robustness of results to variations in key parameters. Based on evidence from current practice, approximately 22% of all risky drinkers in a defined community would reduce alcohol consumption annually, of which about 0.02% would do so because of pharmacist-delivered screening and BI and 1% would do so because of pharmacist screening only. Realistic increments of 10% and 20% in pharmacist-delivered screening and BI would reduce the proportion of risky drinkers by 0.5% and 1.6% at a cost of AUD$50 and AUD$40 respectively, per additional risky drinker reducing alcohol consumption. These findings suggest that increments in pharmacistdelivered screening and BI rates may result in potential cost-effective reductions in alcohol consumption, although its widespread adoption is unlikely to occur because almost all risky drinking pharmacy customers would need to be screened to achieve a reasonable effect size.

Background: Sponsoring of medical meetings by life science companies has led to reduced participation fees for physicians but questions potential drawbacks. Ongoing discussions are proposing to ban such sponsoring which may increase participation fees. Objectives: To evaluate factors associated with general practitioners’ willingness to pay for medical meetings, their support of a binding legislation prohibiting sponsoring and their opinion on alternative financing options. Methods: An anonymous web-based questionnaire was sent to 447 general practitioners’ of one state in Switzerland, identified through their affiliation to a medical association. Results: Of the 115 physicians answering, 48% were willing to pay more than what they currently pay for medical meetings and 79% disagreed that sponsoring introduced a bias in their own prescription practices. In univariate analyses, factors most associated with physician’s willingness to pay were perception of a bias in peers prescription practices (OR=6.67; 95% CI: 1.60-27.74), group practice (OR=3.01; 95% CI: 0.94-9.65) and having <4 meetings with sales representatives per month (OR=2.39; 95% CI: 0.91-6.33). 78% did not support the introduction of a binding legislation and 56% were in favor of creating a general fund set up by life science companies and centrally administered by an independent body as an alternative financing option. Conclusions: Our results suggest that almost half of physicians surveyed were willing to pay more than what they currently pay for medical meetings and that an independent body that would centrally administer a general fund set up by life science companies might be better received by general practitioners’ than a legislation banning the sponsoring of medical meetings by life science companies.

Clostridium difficile infection (CDI) is a public health problem causing severe morbidity and mortality. The clinical presentations of CDI vary from asymptomatic carriage to the full blown pseudo membranous colitis (PMC). With the arrival of the hyper virulent NAP1/BI/027 C. difficile strain, increased incidence of more severe clinical conditions inclusive of PMC, toxic megacolon and intestinal perforation are being reported from the West. Additionally, the recognition of community-acquired CDI signals the presence of several risk factors. Accurate diagnosis of CDI is essential for ongoing epidemiology, optimal treatment and prevention but continues to be challenging. During the past 30 years no standard laboratory test for CDI diagnosis has been clearly established. Diagnostic approaches for CDI are based on several aspects. Clinically the signs and symptoms are watery or bloody diarrhea, abdominal cramps, fever, leukocytosis, etc. PMC can be diagnosed endoscopically as multiple yellow-white friable plaques, a few centimeters in size, attached to the underlying mucosa. Computed tomography scan findings does not help diagnosis, but may help in initiating specific therapy against CDI. Culture can be used for epidemiological and antibiogram purposes during outbreaks. Tissue cultures, enzyme immunoassays and molecular assays are useful to detect C. difficile toxins. Glutamate dehydrogenase test helps to screen out a large number of samples. Toxigenic culture is based on the isolation of C. difficile in culture and then detecting its toxigenic status. The implications of a false negative or a false positive test can lead to disastrous consequence. There are currently two reference assays for the diagnosis of CDI with different targets: the cytotoxicity assay that detects free toxins and the toxigenic culture which detects the organism with the potential to produce toxin. CDI diagnostic testing is an important issue and clinical laboratory professionals should use the assays which give the best performance for the detection of CDI.

Background: Osteoporosis (OP) is reported to be far more prevalent in those with Chronic Obstructive Pulmonary Disease (COPD) than in healthy patients. While these two diseases share many common risk factors, studies suggest that COPD itself may be a contributing factor for poor bone health and thus could serve as a useful indicator to institute treatment for osteoporosis. Our study set out to further elucidate this correlation using structural equation modeling (SEM) in a population attending an academic family health team in Kingston, Ontario. Methods: With ethics approval, data was collected from the existing electronic medical record system of the Queen's University Family Health Team in Kingston, Ontario. A path model with both structural and measurement components testing our hypothesis was constructed using the Structural Equation Modeling (SEM) software (SPSS AMOS 21©) using various latent and manifest variables that include the basic demographics, smoking status, alcohol usage and confirmed diagnoses of COPD and/or OP. Regression and covariance analyses were then performed and results were tabulated for discussions. Results: Our proposed SEM model exhibited a goodness of fit index (GFI) of 0.88, which met the threshold (>0.85) of a good fit for our hypothesis. The correlation between poor lung function and poor bone health showed a statistically significant (p<0.05) positive regression coefficient of 5.753, indicating that poor lung function is indeed indicative of poor bone health. Alternatively, vitamin D and calcium intake in our population were found to have a statistically significant (p<0.001) negative regression coefficient of -0.342, -0.776 respectively, paradoxically implying that positive intake of both vitamin D and calcium is inversely correlated with poor lung function. Moreover, known risk factors for poor lung function such as age and smoking were confirmed with our model, and other factors like gender and alcohol intake were not. Limitations of our study included errors in documentation in the EMR and a biased sample that may not be representative for the general population. Conclusions: Other studies have speculated a correlation between COPD and osteoporosis but definitive data is lacking. We performed a SEM analysis basing on electronic medical record data from an academic family health team in Kingston, Ontario, and our data supported a statistically significant correlation between poor lung function upon poor bone health with due regard to other factors including age, smoking, vitamin D and calcium intake.

Background: The aim of this study was to investigate differences in the awareness of cardiovascular risk factors, preventive action taken and barriers to cardiovascular health between the Turkish minority living in Austria and the indigenous people. Methods: A total of 1800 anonymous questionnaires were handed out to 573 women and 336 men with no immigration background and compared with 257 female and 250 male Turkish migrants in Turkish language living in Austria. Results: Cardiovascular disease was more likely to be identified as the leading cause of death by indigenous Austrians (75%) than by the Turkish participants. Diabetes mellitus II (DM II) was only identified by around 27% of the Austrians and 22% of the Turkish women and 28% of the Turkish men. Albeit Austrians can identify more risk factors and have a lower actual CVD risk, their main barrier to CVD health being the inability to assess their personal risk correctly, while Turkish immigrants show a lack of knowledge of how to access preventive screening. Conclusion: The main barrier for preventive action for the Turkish minority is a low educational and acculturation level, while Austrian women in particular have difficulties in assessing their personal risk correctly.