Annals Journal Club: The Family Physician’s Perceived Role in Preventing and Guiding Hospital Admissions at the End of Life: A Focus Group Study

PURPOSE

Family physicians play a pivotal role in providing end-of-life care and in enabling terminally ill patients to die in familiar surroundings. The purpose of this study was to explore the family physicians’ perceptions of their role and the difficulties they have in preventing and guiding hospital admissions at the end of life.

METHODS

Five focus groups were held with family physicians (N= 39) in Belgium. Discussions were transcribed verbatim and analyzed using a constant comparative approach.

RESULTS

Five key roles in preventing and guiding hospital admissions at the end of life were identified: as a care planner, anticipating future scenarios; as an initiator of decisions in acute situations, mostly in an advisory manner; as a provider of end-of-life care, in which competency and attitude is considered important; as a provider of support, particularly by being available during acute situations; and as a decision maker, taking overall responsibility.

CONCLUSIONS

Family physicians face many different and complex roles and difficulties in preventing and guiding hospital admissions at the end of life. Enhancing the family physician’s role as a gatekeeper to hospital services, offering the physicians more end-of-life care training, and developing or expanding initiatives to support them could contribute to a lower proportion of hospital admissions at the end of life.     

Intra-subspecies sequence variability of the MACPPE12 gene in Mycobacterium avium subsp. hominissuis

The PE (Pro-Glu) and PPE (Pro-Pro-Glu) multigene families are unique to mycobacteria, and are highly expanded in the pathogenic members of this genus. We determined the intra-subspecies genetic variability of the MACPPE12 gene, which is a specific PPE gene in Mycobacterium avium subsp. hominissuis (MAH), using 334 MAH isolates obtained from different isolation sources (222 human isolates, 145 Japanese and 77 Korean; 37 bathroom isolates; and 75 pig isolates). In total, 31 single-nucleotide polymorphisms (SNPs), which consisted of 16 synonymous SNPs and 15 nonsynonymous SNPs, were determined through comparison with the MACPPE12 gene sequence of MAH strain 104 as a reference. As the result, the 334 MAH isolates were classified into 19 and 13 different sequevars at the nucleic acid level (NA types) and amino acid level (AA types), respectively. Among the 13 AA types, only one type, the AA02 type, presented various NA types (7 different types) with synonymous SNPs, whereas all other AA types had a one-to-one correspondence with the NA types. This finding suggests that AA02 is a longer discernible lineage than the other AA types. Therefore, AA02 was classified as an ancestral type of the MACPPE12 gene, whereas the other AA types were classified as modern types. The ubiquitous presence of AA02 in all of the isolation sources and all different sequevars classified by the hsp65 genotype further supports this classification. In contrast to the ancestral type, the modern types showed remarkable differences in distribution between human isolates and pig isolates, and between Japanese isolates and Korean isolates. Divergence of the MACPPE12 gene may thus be a good indicator to characterize MAH strains in certain areas and/or hosts.     

Increased genetic diversity of the Mycobacterium tuberculosis W-Beijing genotype that predominates in eastern China

ObjectivesTo determine the genetic diversity of Mycobacterium tuberculosis (M. tuberculosis) strains in a Chinese population predominately infected with strains of the W-Beijing family.MethodsA cross-sectional study was conducted in three counties of eastern China. M. tuberculosis strains were collected at TB clinics, and patients were interviewed by trained physicians at the time of TB diagnosis. RD105 and RD181 were used to identify W-Beijing and modern W-Beijing strains, respectively, while seven-locus variable numbers of tandem repeat–mycobacterial interspersed repetitive unit (VNTR–MIRU) analysis was employed to differentiate the genotypes of these strains.ResultsOf 441 strains studied, 394 (89.3%) were identified as W-Beijing family strains; of them, 299 were modern W-Beijing strains. VNTR–MIRU identified 409 genotypes from 426 strains, including 395 unique patterns and 14 clusters. Ancestral W-Beijing strains were more likely to be clustered (OR = 1.32, 95%CI: 0.58–2.97) compared to modern W-Beijing strains. The proportions of clustered strains were 14.6%, 4.2% and 0% at sites Funing (FN), Deqing (DQ) and Yinzhou (YZ), respectively. Of the seven MIRU loci, VNTR3820 was found to have the highest discriminatory power and allelic diversity.ConclusionsVNTR–MIRU typing appears to be a reliable method for analyzing M. tuberculosis transmission in relatively closed populations. The low clustering proportions indicate that endogenous relapse may be a main source of TB cases in eastern China. Furthermore, our results indicate that migration has played may play an important role in the recent transmission of the W-Beijing family of M. tuberculosis.     

核事件后持续低剂量辐射水平与人体健康效应的研究进展

日本福岛核事故后,核能、安全、健康是公众关注的焦点。核事件后环境中低剂量辐射水平的放射性核素将长期存在,环境本底的改变是否可能对当地居民的健康存在影响是当前研究的热点,研究人员对此进行了核事件后居民健康流行病学调查和低剂量辐射水平动物实验。本文仅就低剂量照射剂量阈值、放射性核素在人体内的吸收和分布,放射性核素致癌效应的分子机制,剂量-效应外推模型以及国外核事件后持续低剂量辐射水平的居民健康流行病学调查研究进展进行综述。     

2010年我国家庭人均自报食盐消费情况分析

目的 了解2010年我国家庭人均每日食盐消费情况.方法 利用2010年中国慢性病监测家庭问卷调查数据,分析我国家庭人均每日食盐消费量及过量食盐消费比例,描述不同地区、城乡的分布,比较其差异.共有92 814户家庭纳入分析.结果 2010年我国家庭人均食盐摄入10.6 g/d,城市（9.1 g/d）低于农村（11.5 g/d）,东、中、西部地区盐摄入量依次增加,西部农村地区盐摄入量最高（12.5 g/d）,东部城市地区最低（8.6 g/d）.家庭人均每日食盐摄入量超过膳食指南盐摄入建议量（6 g/d）的比例为72.6％,农村（78.3％）高于城市（63.5％）.家庭人均每日食盐摄入量超过我国慢性病防治规划2015年减盐目标（9g/d）的比例为38.1％,农村（44.0％）高于城市（28.8％）,西部地区高于中部和东部.结论 2010年我国家庭人均食盐摄入过高,在西部农村地区尤为突出,需要制定减盐干预策略,加强健康教育,防控高盐饮食危害.