Rodent control in urban communities in Johannesburg,South Africa: from research to action

Introduction:

Rodents are troublesome urban pests, with potentially serious health implications. Preventive efforts require greater understanding of social contexts in which they are prevalent. This study aimed to determine rodent prevalence and identify factors associated with rodent infestations in urban residential settings.

Methods:

The Health, Environment and Development study is a longitudinal panel study conducted in five settlements across Johannesburg. Data on socio-economic status, domestic behaviour and housing quality are collected annually. Logistic regression revealed risk factors for rodent prevalence at household level.

Results:

Rodents are a major household problem in all study areas (prevalence 54%). Factors associated with increased prevalence of rats included lower income, living in informal areas, overcrowding, cracks in dwelling walls and internal damp.

Conclusion:

Socio-economic status, housing quality, domestic behaviour and environmental health services are associated with exposure to rodents in urban Johannesburg communities. This information served as a platform to launch rodent awareness campaigns at study sites.     

Exploring barriers to primary care for migrants in Greece in times of austerity: Perspectives of service providers

Background: Migration in Europe is increasing at an unprecedented rate. There is an urgent need to develop ‘migrant-sensitive healthcare systems’. However, there are many barriers to healthcare for migrants. Despite Greece’s recent, significant experiences of inward migration during a period of economic austerity, little is known about Greek primary care service providers’ experiences of delivering care to migrants.

Objectives: To identify service providers’ views on the barriers to migrant healthcare.

Methods: Qualitative study involving six participatory learning and action (PLA) focus group sessions with nine service providers. Data generation was informed by normalization process theory (NPT). Thematic analysis was applied to identify barriers to efficient migrant healthcare.

Results: Three main provider and system-related barriers emerged: (a) emphasis on major challenges in healthcare provision, (b) low perceived control and effectiveness to support migrant healthcare, and (c) attention to impoverished local population.

Conclusion: The study identified major provider and system-related barriers in the provision of primary healthcare to migrants. It is important for the healthcare system in Greece to provide appropriate supports for communication in cross-cultural consultations for its diversifying population.     

Reproductive and maternity health care services in Finland: perceptions and experiences of Somali-born immigrant women

Objective. To explore immigrant Somali women's experiences of reproductive and maternity health care services (RMHCS) and their perceptions about the service providers.

Design. Five focus group discussions were conducted from April 1999 to June 2000 using a purposeful sampling strategy in order to reach multiparous female Somali-born Immigrants with experiences from the maternity health care in Finland.

Participants. A total of 70 married Somali women aged 18–50 and mother of 2–10 children were studied. Among them, 18 came from Kenya, 32 from Mogadishu and 20 from Hargeysa.

Settings. Of the participants, 45 were living in the city of Vantaa, 22 in the city of Helsinki and 13 in the city of Turku.

Results. Participants were satisfied with the RMHCS they received in Finland. Despite their satisfaction, the health care providers' social attitudes towards them were perceived as unfriendly, and communication as poor.

Conclusions. The women's experiences revealed that they have access to good quality RMHCS in Finland. While their experiences are significant, their perceptions are important for physicians, nurses and midwives in order to achieve culturally competent care.     

Alexithymia is associated with low level of vitamin D in young healthy adults

Objective

Vitamin D plays an important role in brain development and functioning. Low levels of vitamin D have been described in several psychiatric and neurologic conditions including autism spectrum disorder. Alexithymia that shows high comorbidity with autism is also present in the general population as well as hypovitaminosis D.

Methods

Here we assessed the relation between alexithymia as measured by the Toronto Alexithymia Scale-20 and vitamin D level in healthy young adults.

Results

We found an inverse correlation between the levels of alexithymia and vitamin D.

Discussion

These data suggest the association between disturbed emotional processing and low levels of vitamin D to be present in young healthy subjects.     

The effects of interventions on quality of life,morbidity and consultation frequency in frequent attenders in primary care: A systematic review

Background: Patients visiting their GPs exceptionally often (frequent attenders, FAs) have high rates of somatic disease, emotional distress, psychiatric illnesses and social problems and require a disproportionate amount of their GPs’ time.

Objectives: To summarize which types of FA have been studied and what the effects of interventions were on quality of life (QoL), symptom severity of underlying illness(es) and consultation frequency. To discover when patients are considered FAs.

Methods: Systematic review of RCTs using a comprehensive search (MEDLINE, PsycINFO, CINAHL and EMBASE, from 1980 to August 2015) and no language restrictions. Two investigators extracted data. Results were summarized qualitatively.

Results: We included 17 RCTs. Heterogeneity at the level of populations, interventions and outcomes precluded statistical pooling. In-depth analysis by GPs assessing a patient’s reasons for frequent attendance decreased consultation frequency by four to six per year. A small effect on symptom severity was noted in depressed FAs, although this finding was not replicated in a recent trial. Multi-component therapy and medication in FAs with medically unexplained symptoms (MUS) improved QoL (SF36 odds ratio: 1.92; 95%CI: 1.08–3.40) and morbidity (CES-D 3.17; 95%CI: 1.27–5.08).

Conclusion: RCTs on intervention effects in frequent attenders to primary care used different patient populations, interventions, comparators and outcome measures. Consistent evidence on the effects of particular interventions in specific patient domains is lacking. A tailored approach based on in-depth analysis among GPs of potential reasons for frequent attendance may decrease consultation frequency. Research involving the screening and treating for FAs with MUS may be useful in future trials.     

Evidence-based primary care treatment guidelines for skin infections in Europe: A comparative analysis

Background: In Europe, most antibiotics for human use are prescribed in primary care. Incorporating resistance data into treatment guidelines could improve appropriate prescribing, increase treatment effectiveness and control the development of resistance.

Objectives: This study reviews primary care treatment guidelines for bacterial skin infections across Europe and assesses to what extent they are based on antibiotic resistance data.

Methods: Thirteen primary care treatment guidelines were obtained from eight countries across Europe. Both the treatment recommendations and the underlying evidence were assessed. The class and dose of recommended antibiotics were investigated and compared using the World Health Organisation's standardized volume of Defined Daily Dose. Furthermore, analysis investigated whether guidelines included references to scientific publications about antibiotic resistance data, and whether these were of national origin.

Results: Guidelines were included regarding common skin infections in primary care: Impetigo, Cellulitis, Erysipelas, Folliculitis and Furuncle. Results showed a high agreement across Europe: all recommended antibiotics are of the beta-lactam class and mainly in the small spectrum. The advised treatment durations are consistent; the dosages, however, vary considerably, with the highest dosages recommended in Sweden. Seven guidelines (54%) did not include scientific references related to resistance.

Conclusion: There may be a lack of relevant national data on resistance. This study highlights the need to collect more national resistance data (particularly regarding beta-lactams) to create stronger evidence-based treatment guidelines for skin infections in Europe.     

Experienced continuity of care in patients at risk for depression in primary care

Background: Existing studies about continuity of care focus on patients with a severe mental illness.

Objectives: Explore the level of experienced continuity of care of patients at risk for depression in primary care, and compare these to those of patients with heart failure.

Methods: Explorative study comparing patients at risk for depression with chronic heart failure patients. Continuity of care was measured using a patient questionnaire and defined as () number of care providers contacted (personal continuity); () collaboration between care providers in general practice (team continuity) (six items, score 1–5); and () collaboration between GPs and care providers outside general practice (cross-boundary continuity) (four items, score 1–5).

Results: Most patients at risk for depression contacted several care providers throughout the care spectrum in the past year. They experienced high team continuity and low cross-boundary continuity. In their general practice, they contacted more different care providers for their illness than heart failure patients did (P < 0.01). Patients at risk for depression experienced a slightly better collaboration between these care providers in their practice: a mean score of 4.3 per item compared to 4.0 for heart failure patients (P = 0.03). The perceived cross-boundary continuity, however, was reversed: a mean score of 3.5 per item for patients at risk for depression, compared to 4.0 for heart failure patients (P = 0.01).

Conclusion: The explorative comparison between patients at risk for depression and heart failure patients shows small differences in experienced continuity of care. This should be analysed further in a more robust study.     

Book Review

Changing the public health

Rcswch Unit in Health .ad Behaviourd Chutge. University of Edinburgh, John Wdey and Son, London, 1989, ISBN 0 471 91976 4.

The new public health

John Ashtw and RowYd Seymour. Open University Press, 1988. ISBN 0 335 15550 2, £6.95.

Infertility services-a desperate case

N d Pfeilu cmd Allison Qukk. Greater London Association of Community Health Councils, 1988.

A new kind of Doctor

Julian Tudor Hart. Merlin Press, 1988. ISBN 085036 299 7, £11.95 (hardback).     

The value of routine radiography in patients with knee osteoarthritis consulting primary health care: A study of agreement

Background: Radiography is often used routinely by the general practitioner (GP) in knee osteoarthritis (KOA), even though the diagnosis can be made based on clinical findings. However, radiography may also be requested when serious pathology is suspected. The agreement between the radiographic and the GPs clinical diagnosis and the ability of radiography to rule out serious pathology in clinical KOA is unknown, despite that this is important to evaluate the clinical value of radiography.

Objectives: The objectives were to evaluate agreement between the radiographic and clinical diagnosis in KOA; and to describe radiographic features in patients referred from their GP with clinical KOA.

Methods: Referral forms from GPs and radiographs of 1 334 consecutive patients above 40 years not previously diagnosed with KOA were evaluated. The agreement between primary indication for radiographic referral (± clinical KOA; according to the recommendations from the European League Against Rheumatism) and the radiographic diagnosis (± radiographic KOA; Kellgren and Lawrence score ≥ 1) was estimated using Cohen's Κ statistics. Furthermore, an evaluation of radiographic features was carried out in patients with clinical KOA (n = 997).

Results: The strength of the agreement was 0.106 to 0.298 with the lowest agreement in the youngest patients and the highest in the oldest patients. Five radiographs (0.5%) revealed conditions needing further investigation or specific treatment (osteonecrosis, osteochondral lesion, fracture and subluxation).

Conclusion: In patients with clinical KOA, the radiography seems only indicated if the clinical assessment cannot rule out other diagnoses or serious pathology.     

Rapidly increasing prescribing of proton pump inhibitors in primary care despite interventions: A nationwide observational study

Background: Guideline and reimbursement modifications have been introduced to optimize prescribing of antisecretory medication in Danish general practice. Impacts of the interventions have not been evaluated.

Objectives: To analyse developments in prescribing of antisecretory medication in Denmark 2001–2011 and to assess the impacts of interventions on prescribing of antisecretory medication.

Methods: Register-based cohort study covering the entire Danish population of currently 5.5 million inhabitants. Developments in the prescribing of antisecretory medication over time in Denmark between 2001 and 2011 and association with age and gender of users along with the impact of interventions on the prescribing of drug subgroups are analysed.

Results: 96.8% of all antisecretory drugs sold are proton pump inhibitors (PPIs) and 94.4% of the PPIs are prescribed in primary care. Prescribing of PPIs has increased substantially during the past decade. Both number of users and the average individual use have increased. The prescribing of ulcerogenic drugs to the elderly has stagnated in the same time range. Reimbursement modifications and scientific guidelines do not seem to have had a substantial influence on the steadily increasing prescribing of PPIs.

Conclusion: Use of PPIs has increased substantially during the past decade, without a change in indications for use of PPIs in the same time range. Interventions to enhance adherence to guidelines and promote rational use of PPIs do not seem to have had a substantial influence on the overall prescribing rate.     

Reducing the use of out-of-hours primary care services: A survey among Dutch general practitioners

Background: Out-of-hours primary care services have a high general practitioner (GP) workload with increasing costs, while half of all contacts are non-urgent.

Objectives: To identify views of GPs to influence the use of the out-of-hours GP cooperatives.

Methods: Cross-sectional survey study among a random sample of 800 GPs in the Netherlands.

Results: Of the 428 respondents (53.5% response rate), 86.5% confirmed an increase in their workload and 91.8% felt that the number of patient contacts could be reduced. A total of 75.4% GP respondents reported that the 24-h service society was a ‘very important’ reason why patients with non-urgent problems attended the GP cooperative; the equivalent for worry or anxiety was 65.8%, and for easy accessibility, 60.1%. Many GPs (83.9%) believed that the way telephone triage is currently performed contributes to the high use of GP cooperatives. Measures that GPs believed were both desirable and effective in reducing the use of GP cooperatives included co-payment for patients, stricter triage, and a larger role for the telephone consultation doctor. GPs considered patient education, improved telephone accessibility of daytime general practices, more possibilities for same-day appointments, as well as feedback concerning the use of GP cooperatives to practices and triage nurses also desirable, but less effective.

Conclusion: This study provides several clues for influencing the use of GP cooperatives. Further research is needed to examine the impact and safety of these strategies.

Key Messages

• GPs believe that the number of patient contacts with the GP cooperative could be reduced.

• Strategies to reduce the use of GP cooperatives perceived as both effective and advisable by GPs are introducing co-payment for patients, stricter triage and a larger role for the telephone consultation doctor.

     

Family history tools for primary care are not ready yet to be implemented. A systematic review

Background: Taking the family history helps the doctor in estimating the probability of disease in individual patients. However, significant barriers to obtaining adequate family history information remain. Tools overcoming these barriers might support family physicians in this task.

Objective: To review systematically the characteristics of existing family history tools and discuss their potential use in primary care.

Methods: Studies were identified through searches of PubMed, Embase and Cinahl from 1 January 2002 until May 2012. All authors independently screened studies and included original research papers on family history tools of which assessment had been performed or was planned. We reviewed diseases for which family history information was collected, study setting, tool design, type of family history collection, presence of risk-assessment and recommendations for management, and assessment (categorized as either validity or benefit).

Results: Eighteen family history tools were identified: six generic, two on cardiovascular disease and ten on cancer. The six generic tools were partly tested in primary care (3x), are mainly computerized (4x), rarely include management recommendations for the physician (1x) and were partly validated against a reference standard (genetic counsellor) (3x, plus one planned). Of the five specific tools studied in primary care, none was validated. No family history tool allows electronic transfer of family history information to electronic medical record systems. Use of a family history tool improved identification of patients at risk for disease.

Conclusion: Several promising family history tools for primary care have been developed but large-scale implementation cannot be advised yet, based on available validation studies.     

Acceleration of reflex maturation and physical development in suckling rats: effects of a maternal diet containing lipids from goat milk

Objective

To investigate the effects of lipids from goat milk containing conjugated linoleic acids on body weight and reflex ontogeny of neonatal rats treated during the prenatal and suckling periods.

Methods

Three groups were studied: soybean oil (S), coconut oil (C), and goat milk lipids (GM). Reflex maturation (palm grasp, righting reflex, cliff avoidance, vibrissae placing, negative geotaxis, auditory startle, and free-fall righting) as well as body weight evolution were recorded during lactation.

Results

Data demonstrated that the lipids from goat milk accelerated body weight evolution as well as all the reflex maturation investigated (P < 0.05).

Discussion

The supply of goat's milk offered to Wistar rats during pregnancy and lactation provided a variety of fatty acids necessary to accelerate the development of offspring.     

Chronic pain in type 2 diabetic patients: A cross-sectional study in primary care setting

Background: Although diabetes mellitus (DM) is often associated with painful neuropathic syndromes, a significant number of DM patients suffer from non-neuropathic (nociceptive) pain. Unfortunately, there is insufficient data on the epidemiology of nociceptive pain in DM patients and its effect on their quality of life.

Objective: To characterize pain in type 2 DM patients, and assess its effect on their quality of life.

Methods: The study population included 342 type 2 DM patients, 18 years of age and above (mean age 70.7 ± 9.7), who reported having pain. The study questionnaires included the Brief Pain Inventory (BPI), the S-LANSS scale to assess pain with neuropathic features, life impact, and socio-demographic data.

Results: One hundred and fifty-five DM patients (46.5%) reported having pain of predominantly neuropathic origin. Almost 75% of patients with neuropathic pain were females, compared to 57.8% of patients with nociceptive pain (P = 0.002). More patients with neuropathic pain reported constant daily pain (57.6% vs. 42.4%, P < 0.0001), and worse pain during the night (53.3% vs. 46.7%, P = 0.045). The pain affected daily activities, walking capacity, and mood. Patients with neuropathic pain reported a greater negative effect of pain on their quality of life than those with nociceptive pain (41.0% vs. 15.3%, P < 0.0001).

Conclusion: The impact of neuropathic pain in DM patients is much more significant than nociceptive pain and affects their quality of life and daily function to a greater degree.     

Racial discrimination,racial/ethnic segregation,and health behaviors in the CARDIA study

Objective

Racial discrimination has been associated with unhealthy behaviors, but the mechanisms responsible for these associations are not understood and may be related to residential racial segregation. We investigated associations between self-reported racial discrimination and health behaviors before and after controlling for individual- and neighborhood-level characteristics; and potential effect modification of these associations by segregation.

Design

We used data from the longitudinal Coronary Artery Risk Development in Young Adults (CARDIA) study for 1169 African-Americans and 1322 whites. To assess racial discrimination, we used a four category variable to capture the extent and persistence of self-reported discrimination between examination at years 7 (1992–1993) and 15 (2000–2001). We assessed smoking status, alcohol consumption, and physical activity at year 20 (2005–2006). Segregation was examined as the racial/ethnic composition at the Census tract level.

Results

Discrimination was more common in African-Americans (89.1%) than in whites (40.0%). Living in areas with high percentage of blacks was associated with less reports of discrimination in African-Americans but more reports in whites. After adjustment for selected characteristics including individual- and neighborhood-level socioeconomic conditions and segregation, we found significant positive associations of discrimination with smoking and alcohol consumption in African-Americans and with smoking in whites. African-Americans experiencing moderate or high discrimination were more physically active than those reporting no discrimination. Whites reporting some discrimination were also more physically active than those reporting no discrimination. We observed no interactions between discrimination and segregation measures in African-Americans or whites for any of the three health behaviors.

Conclusions

Racial discrimination may impact individuals' adoption of healthy and unhealthy behaviors independent of racial/ethnic segregation. These behaviors may help individuals buffer or reduce the stress of discrimination.     

Dementia with Lewy bodies: The emerging role of primary care

Introduction: Dementia with Lewy bodies (DLB) is an under recognized but frequent subtype of dementia. Misdiagnosis and delays in referral from primary care are common when compared to other forms of dementia.

Case: We present a case of a 63-year-old man who was eventually diagnosed with DLB three and a half years after his initial presentation.

Discussion: Core features of DLB such as hallucinations, Parkinsonism and fluctuating levels of cognition need to be recognized in primary care as being part of the DLB phenotype. DLB is a complex and debilitating neurodegenerative disorder often requiring multidisciplinary support to enable affected individuals to live well in the community. Carers of DLB patients often develop higher levels of subjective burden compared to carers of patients with other forms of dementia; this needs to be recognized and managed appropriately. There is limited research into the role of primary care physicians in DLB. Efforts should be made to reduce delays in identification.

Conclusion: Primary care has an important role in identifying those who are at risk for DLB and in referring these patients timely to the appropriate specialist. Adequate management of these patients in the community might reduce the burden associated with the DLB phenotype.