Undergraduate training in primary health care: 6 years' experience at the University of Alicante

OBJECTIVE: To assess the opinion of medical students on the teaching offered in the Primary Care context (TOPC). DESIGN: Observational and crossover study. The assessment used an opinion questionnaire. PARTICIPANTS: 296 sixth-year medical students between 1987 and 1992. INTERVENTIONS: The TOPC consisted of four weeks stay in a Health Centre with an eminently practical programme. However this also included hour-long theoretical seminars on the most important Primary Care questions and the student's completion of a research project related to Primary Care. RESULTS: The students expressed satisfaction with the TOPC (average score of 4 out of 5). Moreover this satisfaction increased over the five years (from 3.7 to 4.6, p = 0.0001). They believed the TOPC to be useful (3.6 to 4.7, p = 0.0001) and relevant to their future professional activity (3.1 to 4.6, p = 0.0001). They thought that the tutors were very competent (4 out of 5, with no significant variation) and the Health Centres' teaching facilities suitable (3.8 to 4, with no significant variation). Finally, they considered that TOPC should become a compulsory undergraduate subject (3.9 out of 5). CONCLUSIONS: Medical students give a positive rating to the Primary Care teaching offered and believe it should be integrated into the Medicine syllabus as a compulsory subject.     

Factors associated with smoking and the reasons for stopping in Maori and Europeans: a comparative study

AIM: To compare the prevalence of smoking, factors associated with smoking, ex-smokers and reasons for stopping in Maori and Europeans aged 10 years and older. METHODS: Demographic and smoking data were obtained by personal interview using a standard questionnaire and assisted by Maori health carers. Report-back meetings were held. RESULTS: The smoking status in 713 subjects (Maori 52.5%, Europeans 47.5%) was: current smokers (Maori 48.1%, Europeans 19.8%); never smoked (Maori 28.1%, Europeans 47.5%); ex-smokers (Maori 23.8%, Europeans 32.7%). Of Maori smokers, 66.1% were women whereas of European smokers 47.8% were women. Significantly more Maori aged 10 to 29 years smoked than Europeans (p = 0.0002). Nineteen percent of smokers smoked < 5 cigarette equivalents per day, 68.8% smoked 5 to 20, and 12.2% smoked > 20 cigarettes per day. There was no gender difference in cigarette consumption. Maoridom (p = 0.00001), a less skilled occupation (p = 0.0008), lower income (< or = $15,000 p = 0.002) and alcohol consumption (p = 0.00001) were significantly associated with current smoking. Reasons for giving up smoking were health (majority), awareness of risks (Europeans), financial (Maori men), pregnancy (Maori women), social unacceptability (European women), on advice of medical practitioner (minority). CONCLUSIONS: Smoking remains a major problem in New Zealand, particularly in Maori. Stricter anti-tobacco measures than already exist, greater input from medical practitioners and particularly ongoing participation by Maori health carers should lead to a further decline in smoking.     

Self health care when faced with acute pathology in childhood

OBJECTIVE: To quantify and describe the self-care practices for children up to 14 seeking care because of an acute pathology. DESIGN: An observation study carried out by means of a questionnaire administered to the person accompanying the patient. SETTING: Primary Care: an urban Health Centre. PATIENTS AND OTHER PARTICIPANTS: The total number of cases of acute pathology treated during April and May 1993 in the Centre's paediatric clinics. MEASUREMENTS AND MAIN RESULTS: 248 cases were studied (53% boys and 47% girls, with an average age of 5.3 +/- 3.85). Self-care (self-medication, 84.6%; non-pharmacological measures, 11.5%; both of these, 3.9%) was practised in 61.3% of cases (CI 95%: 55.2-67.4). The most common drugs were: antipyretics-analgesics (60%), antitussives (9.6%) and antibiotics (8.1%). Self-care was practised most often on patients presenting respiratory symptoms (69.6%) (p < 0.001), with self-medication predominant (91.2%) (p < 0.001). The number of days occurring between the appearance of symptoms and the medical consultation was greater among those who did not practise self-care (4.5 +/- 5.2 as against 2.1 +/- 1.8) (p < 0.001). CONCLUSIONS: Self-care is a very common practice among people seeking paediatric treatment. Self-medication, especially for respiratory trouble, is the most common form. Patients who practise self-care tend to be earlier in seeking a medical consultation.     

Epidemiology, clinical manifestations, and outcome of Clostridium difficile-associated diarrhea

OBJECTIVE: Clostridium difficile gastrointestinal disease is an important nosocomial infection and is associated with recent antibiotic use. This study evaluated C. difficile-associated diarrhea (CDAD) over a 2-yr period. METHODS: All 60 patients with C. difficile enterotoxin in their stools, and diarrhea, were retrospectively analyzed at a 615-bed teaching hospital. Institution antibiotic usage and discharge medical diagnoses were correlated with the study patients. RESULTS: Thirty-eight study patients (53%) had major or extreme admitting symptoms. Only four (7%) had no co-morbid illness. The incidence of CDAD increased significantly (p < 0.05) after 4 wk of hospitalization. No demographic or temporal clustering was discovered. Leukocytosis (60%), leftward polymorphonuclear shift (47%), dehydration (30%), weight loss (23%), and oliguria (12%) were the major clinical findings. Among these subject 51 (85%) had been on ceftriaxone and/or ceftazidime in the preceding 6 wk; ceftriaxone/ceftazidime was highly significantly associated (p < 0.01) with more cases than expected by usage alone. No patient on ticarcillin/clavulanate developed CDAD, although it was the most commonly used antibiotic (p < 0.00001). Higher mortality was associated with older debilitated nursing home residents. CONCLUSIONS: Third-generation cephalosporin use correlated with the development of CDAD; ticarcillin/clavulanate usage did not. Morbidity and mortality associated with CDAD is significant, is worse in debilitated older nursing home patients, and is more likely to occur in hospitalizations lasting longer than 4 wk.     

The relationship between upper gastrointestinal hemorrhage and drug use: a case control study

The relationship between upper gastrointestinal hemorrhage and drug use was studied in 251 Chinese patients (179 men, 72 women) admitted to the Prince of Wales Hospital, Hong Kong, and control subjects matched for age and sex. There was a highly significant difference between the cases and control subjects in the use of NSAIDs (odds ratio 14.0, p < 0.00001), ulcer healing drugs (odds ratio 12.5, p < 0.00001), and Chinese proprietary medicines (odds ratio 16.0, p < 0.00001). There was also a significant difference in the use of analgesics (odds ratio 14.0, p = 0.001), paracetamol (odds ratio 2.5, p = 0.01), antacids (odds ratio 2.7, p < 0.001) and unknown drugs (odds ratio 4.7, p < 0.001). Cases also differed from control subjects regarding the use of tobacco (odds ratio 2.3, p < 0.001) and alcohol (odds ratio 1.7, p = 0.02), and the presence of peptic ulcer symptoms (odds ratio 29.8, p < 0.00001). Significantly more control subjects than cases were receiving aspirin, cardiovascular drugs, bronchodilators, oral hypoglycemic drugs/lipid-lowering drugs, and anticonvulsants/hypnotics, due to the inevitable differences in disease pattern between the 2 groups. NSAID use was a major factor associated with upper gastrointestinal hemorrhage from primarily peptic ulcers. Differences in the use of other drugs may reflect variations in disease patterns between cases and controls, the common practice of self-medication in Hong Kong, and the concomitant use of NSAIDs and ulcer healing drugs/antacids.     

Mental health facilitators in primary care

In the context of the National Primary Care Facilitation Programme, the Sainsbury Centre for Mental Health has reviewed the membership of the Mental Health in Primary Care Network, and explored members' roles; the findings of the review are reported in this article. Researchers examined the activities undertaken by network members, and identified the proportion working directly with primary health care teams and those working strategically within health authorities. Education and training, health promotion, and liaison and linkworking were undertaken by many staff, while a few worked at a more strategic level. In order to increase the effectiveness of this model, a more focused approach is recommended, targeting those with responsibility for implementing changes and developing mental health care in primary care settings. Learning sets which involve primary care and mental health teams, and strategic work with health authorities, are also recommended.     

Comprehensive clinical assessment in community setting: applicability of the MDS-HC

A cohort of 759 coronary artery bypass grafting (CABG) patients (269 women and 490 men) was enrolled in the prospective POST CABG Biobehavioral Study at 5 clinical centers in the United States and Canada. Sociodemographic and medical data were obtained by interview and from medical charts. Health-related quality of life and psychosocial data were ascertained preoperatively by interview and questionnaire for those patients whose condition allowed preoperative assessment and was compared among patients from hospitals enrolling both male and female patients (143 women and 267 men). Women enrolled in the Biobehavioral Study were older than men (65.4 +/- 9.0 vs 61.8 +/- 9.7 years, p < 0.001) and more likely to have a preoperative medical condition which precluded biobehavioral evaluation (47% vs 34%, p < 0.001). Women were less likely to be high school graduates (59% vs 74%, p < 0.001), were less likely to be earning > or = $25,000 per year (39% vs 69%, p < 0.001), and were married less often at the time of surgery (59% vs 85%, p < 0.001). Fewer women than men were able to perform basic self-care activities (p < 0.001) and social activities (p < 0.001). Women were also less able to perform the more demanding activities required for independent living, recreation, and maintaining a household (p < 0.001). Women were also more anxious (p = 0.01) and reported more depressive symptoms (p < 0.001) than men. These data suggest that plans for perioperative and convalescent care for women undergoing CABG should take into account their less favorable medical and psychosocial status relative to men.     

Pancreatoduodenectomy in abdominal trauma: a viable alternative

Accidents are the leading cause of death in children and a major factor in lost productive life. This case-control study investigates childhood accidents in the home by randomly surveying children presenting to a Dublin Accident and Emergency Department. Risk factors for home accidents are examined by comparing cases (those with accidental injuries sustained at home) with controls. Of the 174 accident attenders, 59.2% were boys; 66% of all surveyed were under 5 years. Cases were more likely to belong to Social Class 5-6 (P < 0.01), their fathers were less likely to be employed (p < 0.01) and mothers were less likely to be working outside the home (P < 0.01). Over 50% of injuries were due to falls (50.8%). Blows and cuts accounted for 22.6% of injuries, while 13% were due to burns, 7.9% were due to poisoning, and 5.7% due to foreign bodies. Children under 5 were more likely than older children to have been supervised at the time of the accident. Most of the injuries were minor. However, 34 children (19.5%) required hospital admission. Measures to prevent accidents at home should be targeted towards those at most risk-parents of pre-school children and the lower social class groups. Accident prevention requires a three-pronged approach i.e. environmental change, enforcement of legislation and educational measures.     

Outcomes of spherocylinder treatments in the comprehensive refractive surgery LASIK study

OBJECTIVE: To investigate the number of people with intolerance to glucose (ITG) and undiagnosed diabetes (DM) among primary care users at risk. DESIGN: Prospective, selective urban polling of a representative sample of those attended in the city of Reus (88,000 inhabitants). SETTING: Two base health areas (10 Primary Care teams) with an approximate overall reference population of 45,000 inhabitants. PATIENTS AND OTHER PARTICIPANTS: Clinical and examination data were recorded with a pre-designed questionnaire. Diagnoses were established by means of base glycaemia (mmol.l-1 or a 75 g glucose oral overload (0 and 120 minutes) for users over 40 with some Diabetes risk factor. Further tests were HbA1C (%), base peptide-C (nmol.l-1, total cholesterol, HDL cholesterol, triglycerides (mmol.l-1 and 24-hour microalbuminuria (mg). MEASUREMENTS AND MAIN RESULTS: After a year included in the survey, the data of 345 people were evaluated: 151 men, 58 years old (95% CI, 57-60) and BMI of 30.8 (30.3-31.4), with 197 diagnoses (57.1%) of normal tolerance to glucose (52-62%). 82 (23.8%) of ITG (20-28%) and 66 (19.1%) of undiagnosed DM (15-23%). Significant differences between the three were detected in age (56/61.5/61.7 years, p < 0.001), proportion of men (38/50/53%, p < 0.05), diagnosis of hypertension (40.6/59.8/53%, p < 0.01), previous anomaly in tolerance 28.4/45.1/51.5%; p < 0.001), HbA1C (4.6/4.9/5.4; p < 0.001), systolic pressure (140.5/143.6/151 mmHg, p < 0.007). Triglycerides (1.4/1.6/2.1, p < 0.001) and microalbuminuria (16/29/51, p < 0.001). Base peptide-C (3.5/3.8/3.8) showed no statistical differences. CONCLUSIONS: Selective detection in primary care amply exceeds opportunist detection in identifying patients with ITG who might be susceptible to preventive measures. In function of the intolerance level, from normality through to DM, statistical differences were found in HbA1C, systolic pressure, Triglyceridaemia and urinary excretion of albumin. These were not extendable to the rest of the lipid profile or to endogenous insulinaemia.     

Prevention of cardiovascular disease within the primary health care system--feasibility of a prevention programme within the Sollentuna primary health care catchment area

OBJECTIVE: To integrate prevention of cardiovascular disease within the primary health care. DESIGN: A prevention programme which combines population and individual high-risk strategy. SETTING: The Primary Health Care in Sollentuna, Stockholm, Sweden. MAIN OUTCOME MEASURE: Characteristics of, and risk factor prevalence among, persons registered in the prevention programme. RESULTS: During the first year more than 2000 persons, representing every tenth visitor and 6% of the population aged 15-60 years, were registered in the prevention programme. 90% were < or = 60 years and 62% were women. A large proportion (70%) had risk factors that required advice, treatment, and follow up. 24% of the men and 27% of the women were smokers, 68% and 62% respectively, had serum cholesterol > or = 5.2 mmol/l, and 33% and 22% had a diastolic blood pressure > or = 90 mmHg. CONCLUSION: The present study implies that it is possible to integrate a large scale prevention programme in the existing primary health care organization. The prevalence of risk factors in those who enter the prevention programme is high, which places great demands for treatment and follow up.     

Evaluation of the completion of influenza vaccination

OBJECTIVE: To find the reasons which determine failures to comply with anti-flu vaccinations, so that these can be corrected and the coverage of this preventive action be increased. DESIGN: Observational crossover study, done by means of a telephone survey of people over 65. A questionnaire with closed questions, composed after a pilot study and validated by Cronbach's alpha. SETTING: Primary Care Centre (PCC). PATIENTS: We calculated a population sample for qualitative variables (_ = 0.05; p = 0.60; e = 0.05) of 294 people over 65, chosen from the PCC records, by means of random sampling (K = 4) stratified for age and discounting the telephone selection bias. MEASUREMENTS AND RESULTS: The proportion of vaccinated patients (60.9%) obtained in our study did not significantly differ from that in the general population. The percentage of patients included in the programme for the first time was 14%. Level of satisfaction among those vaccinated was 89.4%, with 8.9% of problems detected being light. Main causes of non-vaccination were: thinking that they didn't need it (63.5%), ignorance of the campaign (35.7%), fear of the reaction (24.3%), forgetting (10.4%). The main form of access to the campaign information was from the PCC, both through individuals and posters. Lack of information was statistically significant (p < 0.00001) as a determinant of non-vaccination, without other factors (age, sex, associated pathologies...) explaining these differences. CONCLUSIONS: Individualised and on-going health education by the PCC is fundamental. This would enable the identification of the group not vaccinated due to their express refusal and the recovery of non-vaccinated patients.     

Effect of a monitored care unit on resource utilization in a pediatric ICU

The prevalence and predisposing conditions for primary and secondary Raynaud's phenomenon (RP) were examined in The Framingham Study based on 16 years of follow-up of a cohort of 4182 men and women. The association with atypical chest pain and migraine headache was also investigated. Over the 16 years of follow-up there were 130 men and 171 women who developed primary RP. The prevalence in women (9.6%) was somewhat higher than in men (8.1%) and 81.4% of the RP was primary. Secondary RP was equally prevalent in men (18.6%) and women (19.7%). The most common causes of secondary RP were beta-blocker use (34.2%), carpal tunnel syndrome (10.5%) and rheumatoid arthritis (7.2%). Primary RP cases differed from noncases by having lower systolic blood pressure (p < or = 0.001) and diastolic blood pressure (p < 0.0001), and more coronary disease (p = 0.009), smoking (p < or = 0.01) and higher blood sugars (p < or = 0.009). Atypical chest pain was present more often than noted previously in The Framingham Study general population survey, and was equally prevalent in primary and secondary RP and in the two sexes. Associated migraine was more prevalent in women (14.4%) than men (5.0%). Vibrating tool use with associated RP occurred in 14.6%.     

Experience with the Ultrex and Ultrex Plus inflatable penile prosthesis: new implantation techniques and surgical outcome

OBJECTIVE: To construct nomograms of the size of the fetal orbit and lens during gestation. SUBJECTS: The study group included 349 normal pregnant women at 14-36 weeks' gestation. METHODS: Routine biometric measurements were obtained in all the participants; these included biparietal diameter, head and abdominal circumferences, measurements of the long bones and the diameters of the fetal orbit and lens. The orbital and lens circumference measurements were also related to gestational ages. RESULTS: A linear growth function was observed between gestational age (GA) and orbital diameter (r = 0.94; p < 0.00001; y = -0.66 + 0.5 x GA), orbital circumference (r = 0.94; p < 0.00001; y = -2.1 + 1.5 x GA) and orbital area (r = 0.94; p < 0.00001; y = -98.1 + 8.3 x GA). Significant correlation was also found between femoral length (FL) and orbital diameter (r = 0.95; p < 0.00001; y = 3.3 + 1.9 x FL), orbital circumference (r = 0.95; p < 0.00001; y = 10.3 + 5.9 x FL) and orbital area (r = 0.93; p < 0.00001; y = -28.2 + 32.2 x FL). A linear growth function was observed between orbital circumference and biparietal diameter (r = 0.94; p < 0.00001) and head circumference (r = 0.95; p < 0.00001). A linear growth function was also observed between gestational age and the diameter of the lens (r = 0.89; p < 0.00001; y = 0.88 + 1.4 x GA) the circumference of the lens (r = 0.89; p < 0.00001; y = 2.78 + 0.4 x GA) and the area of the lens (r = 0.89; p < 0.00001; y = -7.95 + 1.0 x GA). The correlation was found between the ratios of the diameters, circumferences and areas of the lens and the orbit. CONCLUSIONS: These results provide normative data of the growth of the fetal orbit and lens and may aid future studies relating to fetal eye anomalies.     

Factors involved in noncompliance with drug treatment in non-insulin dependent diabetes mellitus

OBJECTIVE: To find the level of non-compliance with treatment with oral hypoglycemics, its causes and the profile of non-compliant patients. DESIGN: Prospective study. SETTING: Primary Care Centres in the province of Alicante. PATIENTS: 107 diabetics not dependent on insulin on the lists of five General Medicine practices and all receiving pharmacological treatment. MEASUREMENTS AND MAIN RESULTS: The method used to value compliance was a surprise count of pills in the patient's home. Patients achieving 80-110% compliance were considered compliant. The level of non-compliance was 51.5% (C.I. 42.1%-61%), 36.5% being hypocompliers and 15% hypercompliers. Forgetting (40.7%) and lack of knowledge (29.5%) were the most frequent reasons for non-compliance. The factors associated with non-compliance were: over four years evolution of the disease (p = 0.02), the diet not properly observed (p = 0.03), over a year in regular treatment (p = 0.006), poor control of the disease valued by HbA1C (p = 0.003). CONCLUSIONS: A high level of non-compliance with pharmacological treatment was found for patients with Diabetes Mellitus not dependent on insulin. Its causes were identified and factors associated with poor compliance were profiled.