Operationalization of the One Health approach in two rural municipalities of Niger

Despite multiple efforts made by its government to improve public health, Niger still regularly faces numerous disasters including epidemics. Between 2017 and 2019, a consortium was established between Doctors of the World and Veterinarians Without Borders to implement a “One Health” project. This approach aims to reduce the populations' vulnerabilities to health risks related to environmental disasters and improve the health system's resilience at several levels. By promoting interdisciplinary between human, veterinary and environmental health issues, it aims to tackle emerging diseases with pandemic risk. The project was implemented in 2 municipalities: Sakoira and Ingall. For the first time, a program focused on preventing health and environmental risks rather than responding to a crisis.

An external evaluation based on 278 interviews identified 5 project's achievements: (1) the increase in availability and accessibility of human and veterinary pharmaceutical products which improved vaccination coverage and medicalization while lowering treatment and prevention costs; (2) the mobilization and coordination of human and animal health professionals, national authorities and municipalities; (3) the strengthening of joint epidemiological surveillance through professional and community actors in order to reduce the response time to epidemics and disasters; (4) the strengthening of communities' understanding of health risks and how to prevent them; (5) the capacity building of professionals regarding the One Health approach at national, regional and local level.

Coordination between human and animal health professionals has made possible the design and implementation of joint actions. These actions have enabled to: build capacity for 43 health providers, 116 community health workers and 41 livestock auxiliaries, vaccinate, de-worm and treat 24311 small and 7590 large ruminants, give primary health care to 4190 people, sensitize 2268 people on human and animal health.

Key messages

The project is innovative as it focuses on preventing epidemic risks instead of responding to crisis. Collaboration between human and animal health actors is the main success factor of the project.

Quick and collaborative response to teenage pregnancies in a poor semi-rural area of Belgium

Early pregnancies are often linked to precarious situations. Even if Belgium has seen a decrease in teenage pregnancies, in the former mining region of the Hainaut there are still twice as many births to young women under 20 compared to the national rate.

Colfontaine is one of the poorest cities in Belgium. Last year, one of the local high schools counted 10 pregnant teenagers out of 450 students. Médecins du Monde was already present in the city at the time with a mobile health clinic called the Médibus. In response, we carried out a mapping of the local sexual and reproductive health actors. The lack of accessibility to social and health structures capable of welcoming teenagers anonymously and free of charge quickly emerged as a problem, the nearest family planning center being located 30 minutes away by bus.

In September 2019, in partnership with 5 local health actors, we decided to reshape the Médibus into the Adobus in order to offer family planning consultations, health promotion and harm reduction activities at the high school once a week.

In addition to offering health information services, we also aim to detect teenagers experiencing vulnerable situations such as addiction, violence, gender issues and refer them to appropriate services. Halfway through the project, we met 430 teenagers in 14 afternoons. The most common reasons for consultation (N = 310) were questions related to contraception for 29% and to sexually transmitted infections for 24,5%. 70,9% of teenagers received condoms and 13 girls were tested for pregnancy. One girl received a morning-after pill. 3 teenagers with addiction problems and 17 victims of violence were detected. The teams referred 18 teenagers to other services.

The success of this outreach project confirms the need for information regarding sexual and reproductive health for teenagers living in precarious situations as well as the need to develop reachable and affordable sexual and reproductive health services in semi-rural areas.

Key messages

Outreach is an efficient approach to respond to teenagers’ needs in poor semi-rural areas. Outreach facilitated the detection of early pregnancies, addiction and violence issues among teenagers.

Quality of care assessment for people with multimorbidity

Multimorbidity, the simultaneous presence of multiple health conditions in an individual, is an increasingly common phenomenon globally. The systematic assessment of the quality of care delivered to people with multimorbidity will be key to informing the organization of services for meeting their complex needs. Yet, current assessments tend to focus on single conditions and do not capture the complex processes that are required for providing care for people with multimorbidity. We conducted a scoping review on quality of care and multimorbidity in selected databases in June 2018 and identified 87 documents as eligible for review, predominantly original research and reviews from North America, Europe and Australasia and mostly frequently related to primary care settings. We synthesized data qualitatively in terms of perceived challenges, evidence and proposed metrics. Findings reveal that the association between quality of care and multimorbidity is complex and depends on the conditions involved (quality appears to be higher for those with concordant conditions, and lower in the presence of discordant conditions) and the approach used for measuring quality (quality appears to be higher in people with multimorbidity when measured using condition/drug-specific process or intermediate outcome indicators, and worse when using patient-centred reports of experiences of care). People with discordant multimorbidity may be disadvantaged by current approaches to quality assessment, particularly when they are linked to financial incentives. A better understanding of models of care that best meet the needs of this group is needed for developing appropriate quality assessment frameworks. Capturing patient preferences and values and incorporate patients' voices in the form of patient-reported experiences and outcomes of care will be critical towards the achievement of high-performing health systems that are responsive to the needs of people with multimorbidity.

Parental separation and behaviours that influence the health of infants aged 28 to 32 months: a cross-sectional study

Background

In Western countries, many children are affected by the separation of their parents.

The study’s main objective was to analyse the parental behaviours potentially influential for preschool children’s health by family structure (parents together or separated).

Methods

We conducted a cross-sectional study based on data collected from examinations as part of free preventive medical consultations in the French Community of Belgium. During the assessment of 30,769 infants aged 28 to 32 months, information was collected on the parents’ use of tobacco, brushing of the infant’s teeth, being monitored by a dentist, and receiving vision screening. The chi² test was applied and the odds ratios were derived to compare the two groups of children (exposed/not exposed to parental separation). Multivariate logistic regression analyses were used to adjust the effect of exposure.

Results

Nearly one in ten (9.8%) did not live with both parents under the same roof. Taking into account the social and cultural environment and other potential confounders at our disposal, we found that in the event of parental separation, behaviours differ in comparison with situations where parents live together; the adjusted odds ratios (ORs) (95% confidence interval) for the infant’s exposure to tobacco, absence of teeth brushing, lack of monitoring by a dentist and absence of visual screening, were respectively 1.7 (1.2–2.0), 1.1 (0.9–1.2), 1.3 (1.1–1.6), 1.2 (1.1–1.2), and 1.2 (1.1–1.4).

Conclusions

This study confirms the suspicion that parental separation is an independent risk factor for parental behaviours that negatively influence the infant’s health. If these results are confirmed, this it could affect the work of the family doctors and paediatricians, especially in terms of family support and information to parents.

[Ethical, pedagogical, socio-political and anthropological implications of quaternary prevention]

The concept of quaternary prevention, resulting from a reflection on the doctor-patient relationship, is presented as a renewal of the ageold ethical requirement: first, a doctor must not harm; second, the doctor must control himself/herself. The origin of the concept, its endorsement by the World Organization of Family Doctors (WONCA) and the European Union of General Practitioners (UEMO), its dissemination, and the debates to which it has given rise, are presented by a panel of authors from 12 countries and 3 continents. This collective text deals more specifically with the ethics of prevention, the importance of teaching Quaternary prevention and Evidence Based Medicine, the social and political implications of the concept of quaternary prevention, and its anthropological dimensions.

Parental separation: a risk for the psychomotor development of children aged 28 to 32 months? A cross-sectional study

BACKGROUND

In Western countries, about a quarter of children are affected by parental separation and a number of authors have previously investigated how familial structure impacts children's health. The purpose of the work: to analyze the psychomotor development of children aged 28 to 32 months based on family structure (parents together or separated), independently of the influence of socio-economic environment that is well documented. To analyse the psychomotor development of children younger than 3 years based on family structure (parents together or separated) independently of the influence of socio-economic environment that is well documented.

METHODS

Cross-sectional study by examination of 28 871 children as part of a free preventive medicine consultation. The data came from an assessment conducted 28 to 32 months after birth during which information was collected about the psychomotor development: to perform a standing jump, dress themselves, draw a vertical line and circle, use the "I" pronoun, build a three-word sentence, and say their first name

RESULTS

Ten percent of the children had separated parents. Compared to parents who were together, when adjusting for the socioeconomic environment, as well as all potential confounders, the adjusted odds ratios (ORs) (95 % confidence interval [CI]) for children with separated parents, in terms of their ability to perform a standing jump, dress themselves, and draw a vertical line and circle were respectively 0.9 (0.7-1.1), 1.1 (0.9-1.2), 1.3 (1.1-1.4) and 1.2 (1.1-1.4). The adjusted ORs (95 % CI) for children's inability to say the "I" pronoun, build a three-word sentence, and say their first name were respectively 1.2 (1.1-1.3), 1.3 (1.2-1.5), and 1.2 (0.9-1.5).

CONCLUSIONS

After adjusting for sociocultural factors and other potential confounders, we observed that the children exhibited slower progression in psychomotor development, especially in language and graphic abilities when their parents were separated. While the implications of our study are somewhat limited, they do provide us with the necessary arguments enabling us to set up a prospective cohort study. Such a study should be able to better assess the impact of parental separation on the child's development, confirming our preliminary results.

An optimization algorithm for individualized biomechanical analysis and simulation of tibia fractures

An algorithmic strategy to determine the minimal fusion area of a tibia pseudarthrosis to achieve mechanical stability is presented. For this purpose, a workflow capable for implementation into clinical routine workup of tibia pseudarthrosis was developed using visual computing algorithms for image segmentation, that is a coarsening protocol to reduce computational effort resulting in an individualized volume-mesh based on computed tomography data. An algorithm detecting the minimal amount of fracture union necessary to allow physiological loading without subjecting the implant to stresses and strains that might result in implant failure is developed. The feasibility of the algorithm in terms of computational effort is demonstrated. Numerical finite element simulations show that the minimal fusion area of a tibia pseudarthrosis can be less than 90% of the full circumferential area given a defined maximal von Mises stress in the implant of 80% of the total stress arising in a complete pseudarthrosis of the tibia.

Common patterns of morbidity and multi-morbidity and their impact on health-related quality of life: evidence from a national survey

Background

There is limited evidence about the impact of specific patterns of multi-morbidity on health-related quality of life (HRQoL) from large samples of adult subjects.

Methods

We used data from the English General Practice Patient Survey 2011–2012. We defined multi-morbidity as the presence of two or more of 12 self-reported conditions or another (unspecified) long-term health problem. We investigated differences in HRQoL (EQ-5D scores) associated with combinations of these conditions after adjusting for age, gender, ethnicity, socio-economic deprivation and the presence of a recent illness or injury. Analyses were based on 831,537 responses from patients aged 18 years or older in 8,254 primary care practices in England.

Results

Of respondents, 23 % reported two or more chronic conditions (ranging from 7 % of those under 45 years of age to 51 % of those 65 years or older). Multi-morbidity was more common among women, White individuals and respondents from socio-economically deprived areas. Neurological problems, mental health problems, arthritis and long-term back problem were associated with the greatest HRQoL deficits. The presence of three or more conditions was commonly associated with greater reduction in quality of life than that implied by the sum of the differences associated with the individual conditions. The decline in quality of life associated with an additional condition in people with two and three physical conditions was less for older people than for younger people. Multi-morbidity was associated with a substantially worse HRQoL in diabetes than in other long-term conditions. With the exception of neurological conditions, the presence of a comorbid mental health problem had a more adverse effect on HRQoL than any single comorbid physical condition.

Conclusion

Patients with multi-morbid diabetes, arthritis, neurological, or long-term mental health problems have significantly lower quality of life than other people. People with long-term health conditions require integrated mental and physical healthcare services.

Electronic supplementary material

The online version of this article (doi:10.1007/s11136-014-0820-7) contains supplementary material, which is available to authorized users.

Care plans and care planning in long-term conditions: a conceptual model

The prevalence and impact of long-term conditions continues to rise. Care planning for people with long-term conditions has been a policy priority for chronic disease management in a number of health-care systems. However, patients and providers appear unclear about the formulation and implementation of care planning. Further work in this area is therefore required to inform the development, implementation and evaluation of future care planning initiatives. We distinguish between 'care planning' (the process by which health-care professionals and patients discuss, agree and review an action plan to achieve the goals or behaviour change of most relevance and concern to the patient) and a 'care plan' (a written document recording the outcome of a care planning process). We propose a typology of care planning and care plans with three core dimensions: perspective (patient or professional), scope (a focus on goals or on behaviours) and networks (confined to the professional-patient dyad or extending to the entire care network). In addition, we draw on psychological models of mediation and moderation to outline potential mechanisms through which care planning and care plans may lead to improved outcomes for both patients and the wider health-care system. The proposed typology of care planning and care plans offered here, along with the model of the process by which care planning may influence outcomes, provide a useful framework for future policy developments and evaluations. Empirical work is required to explore the degree to which current care planning approaches and care plans can be described according to these dimensions, and the factors that determine which types of patients and professionals use which type of care plans.

Parental separation and behaviours that influence the health of infants aged 7-11 months: a cross-sectional study

OBJECTIVE

Analyse the parental behaviours that are recognised as influencing the health of very young children based on family structure (parents separated or not).

DESIGN

Cross-sectional study.

SETTING

Free preventive medicine consultations in the French Community of Belgium.

PARTICIPANTS

Examination of 79 701 infants aged 7-11 months as part of a free preventive medicine consultation. The data came from an assessment conducted 7-11 months after birth during which information was collected, namely about the parents' use of tobacco, the infant's type of nutrition and adherence to vaccination schedules.

MAIN OUTCOME MEASURES

Parental behaviours: smoking, nutrition and compliance with vaccination schedule.

RESULTS

The percentage of infants whose parents were separated was 6.6%. After adjusting for the cultural and socioeconomic environment as well as for other potential confounders, in the event of separation as compared with non-separated parents, the adjusted ORs (95% CI) were as follows: 1.5 (1.3 to 1.7) for the infant's exposure to tobacco; 1.3 (1.2 to 1.4) for total lack of exclusive breast feeding; 1.3 (1.1 to 1.4) and 1.2 (1.1 to 1.2) for breast feeding for a duration of less than 3 and 6 months, respectively; 1.2 (1.1 to 1.4) for non-compliance with the vaccination schedule against rotavirus. The duration of exclusive breast feeding was shorter when parents were separated (p<0.001; median 10 vs 13 weeks).

CONCLUSIONS

This study reinforces the possibility that parental separation is independently associated with certain parental at-risk behaviours regarding the children's health. This observation should be verified because this could result in major consequences for the work of family doctors, in particular in terms of parent information and targeted prevention.

Peginterferon and ribavirin for treatment of recurrent hepatitis C disease in HCV-HIV coinfected liver transplant recipients

Achievement of a sustained virologic response (SVR) with antiviral therapy significantly improves graft survival in hepatitis C virus (HCV) monoinfected liver transplant (LT) patients. Risks and benefits of HCV therapy in HCV-human immunodeficiency virus (HIV) coinfected LT recipients are not well established. Among 89 HCV-HIV LT recipients in the HIVTR cohort, 39 (23% Black, 79% genotype 1, 83% fibrosis stage ≤ 1) were treated with peginterferon-a2a or a2b plus ribavirin for a median 363 days (14-1373). On intent-to-treat basis, 22% (95% CI: 10-39) and 14% (95% CI: 5-30) achieved an end-of-treatment response (EOTR) and SVR, respectively. By per-protocol analysis (completed 48 weeks of therapy ± dose reductions), 42% and 26% had EOTR and SVR, respectively. Severe adverse events occurred in 85%, with 26% hospitalized with infections and 13% developing acute rejection. Early discontinuations and dose reductions occurred in 38% and 82%, respectively, despite use of growth factors in 85%. Eighteen of 39 treated patients (46%) subsequently died/had graft loss, with 10 (26%) attributed to recurrent HCV. In conclusion, SVR rates are low and tolerability is poor in HCV-HIV coinfected transplant recipients treated with peginterferon and ribavirin. These results highlight the critical need for better tolerated and more efficacious HCV therapies for HCV-HIV coinfected transplant recipients.

Molecular weights of free and drug-loaded nanoparticles

This study demonstrates that the molecular weight of polyalkylcyanoacrylate nanoparticles can be modified by the composition of the polymerization medium, the nature of the monomers and the drug to be linked to the carrier. The influence of a surfactive agent is particularly important because polymers of very high molecular weight have been obtained. Likewise, polyalkylcyanoacrylate molecular weight distribution has been greatly modified after binding doxorubicin to nanoparticles. These long polymers could induce important changes in carrier degradation, in bound drug bioavailability and in polymer excretion rate. Some additional findings have been added concerning the state of polyalkylcyanoacrylate polymer during the degradation process.

Socio-demographic inequalities in stage of cancer diagnosis: evidence from patients with female breast, lung, colon, rectal, prostate, renal, bladder, melanoma, ovarian and endometrial cancer

BACKGROUND

Understanding socio-demographic inequalities in stage at diagnosis can inform priorities for cancer control.

PATIENTS AND METHODS

We analysed data on the stage at diagnosis of East of England patients diagnosed with any of 10 common cancers, 2006-2010. Stage information was available on 88 657 of 98 942 tumours (89.6%).

RESULTS

Substantial socio-demographic inequalities in advanced stage at diagnosis (i.e. stage III/IV) existed for seven cancers, but their magnitude and direction varied greatly by cancer: advanced stage at diagnosis was more likely for older patients with melanoma but less likely for older patients with lung cancer [odds ratios for 75-79 versus 65-69 1.60 (1.38-1.86) and 0.83 (0.77-0.89), respectively]. Deprived patients were more likely to be diagnosed in advanced stage for melanoma, prostate, endometrial and (female) breast cancer: odds ratios (most versus least deprived quintile) from 2.24 (1.66-3.03) for melanoma to 1.31 (1.15-1.49) for breast cancer. In England, elimination of socio-demographic inequalities in stage at diagnosis could decrease the number of patients with cancer diagnosed in advanced stage by ∼5600 annually.

CONCLUSIONS

There are substantial socio-demographic inequalities in stage at diagnosis for most cancers. Earlier detection interventions and policies can be targeted on patients at higher risk of advanced stage diagnosis.

Collapsing glomerulopathy associated lupus in a black female with homozygous APOL1 mutation

Collapsing glomerulopathy (CG), characterized by collapse of the glomerular capillary loops onto the mesangial stalks is rarely associated to systemic lupus erythematosus (SLE). Recently a genetic predisposition to HIV associated nephropathy (HIVAN) has been shown in Afro-Americans: MYH9 polymorhism in 2008 and then APOL1 variants (G1 and G2 alleles) in 2010 were shown to be strongly associated with HIVAN. We describe here for the first time the association of CG in a young Afro-American female with SLE having a homozygous mutation of APOL1. The clinical history, laboratory findings and immunofluorescence all confirmed a diagnosis of SLE. However, studies for factors associated with collapsing glomerulopathy in other situations were consistently negative. As this Afro-American patient developed a CG, we performed genotyping of APOL1. It was found that she is homozygotic for the G2 allele of APOL1. Despite.

[Conceptual structure of the electronic health record]

The file is the daily work tool for any physician, general practitioner or specialist. The general practitioner's must of course contribute to the quality of care for his patients, but also has to be used to communicate and exchange relevant clinical information to ensure continuity. A common structure for all the files of first line is therefore essential. For several years, Belgium has played a pioneering role in this matter and several successive working groups led to the development of a standard, which is described in this article. This one became a label and quality criterion for all electronic health records of family doctors.

Understanding ethnic and other socio-demographic differences in patient experience of primary care: evidence from the English General Practice Patient Survey

BACKGROUND

Ethnic minorities and some other patient groups consistently report lower scores on patient surveys, but the reasons for this are unclear. This study examined whether low scores of ethnic minority and other socio-demographic groups reflect their concentration in poorly performing primary care practices, and whether any remaining differences are consistent across practices.

METHODS

Using data from the 2009 English General Practice Patient Survey (2 163 456 respondents from 8267 general practices) this study examined associations between patient socio-demographic characteristics and 11 measures of patient-reported experience.

FINDINGS

South Asian and Chinese patients, younger patients, and those in poor health reported a less positive primary care experience than White patients, older patients and those in better health. For doctor communication, about half of the overall difference associated with South Asian patients (ranging from -6 to -9 percentage points) could be explained by their concentration in practices with low scores, but the other half arose because they reported less positive experiences than White patients in the same practices. Practices varied considerably in the direction and extent of ethnic differences. In some practices ethnic minority patients reported better experience than White patients. Differences associated with gender, Black ethnicity and deprivation were small and inconsistent.

CONCLUSION

Substantial ethnic differences in patient experience exist in a national healthcare system providing universal coverage. Improving the experience of patients in low-scoring practices would not only improve the quality of care provided to their White patients but it would also substantially reduce ethnic group differences in patient experience. There were large variations in the experiences reported by ethnic minority patients in different practices: practices with high patient experience scores from ethnic minority patients could be studied as models for quality improvement.

[Burnout of general practitioners in Belgium: societal consequences and paths to solutions]

The definition of burn-out the most often cited and proposed by Maslach and Jackson, clarifies the three cardinal symptoms affecting doctors, namely, emotional exhaustion, with depersonalization of their patients and reduction of the feeling of personal accomplishment. The causes of this phenomenon are relatively well-known: individual psychological factors, stressful factors intrinsic to the medical practice and finally extrinsic factors related to the professional environment and its organization. The purpose of this review is to estimate the prevalence of burnout within the population of Belgian family physicians and to understand both individual and societal consequences. About the method. This is a literature review using databases Medline, Cochrane Library, and the American Psychological Association from 2000 to 2011 with the keywords: primary health care, family practice, burnout, emotional exhaustion, psychological stressors, distress, fatigue, depersonalization, substance and alcohol abuse, depression, well-being, quality of life, job satisfaction, professional efficiency, patient care, physician-patient relations, medical errors, quality of health care, pharmaceutical/health expenditure/statistics-numerical data, obstacles to prevention, health system assessment, medical demography. Selecting of the most relevant articles through the reading of abstracts and then full text reading of 49 selected articles. In conclusion, the exact prevalence of burn-out amongst Belgian general practitioners is not known. From some works, it is estimated that about half of them would be achieved at least in terms of emotional exhaustion. The symptoms related to burn-out are potentially serious: ea depression, alcohol and tobacco abuse and cardiovascular complications. There are also arguments demonstrating the fact that this disorder amongst general practitioners influences negatively the quality of care, their cost, but also medical demography of primary care with as a corollary a questioning of the viability of the health care system as we know it. At the time of writing this article, the Belgian Health Care Knowledge Centre (KCE) is completing, at the request of the Belgian Ministry (SPF) of Health a study entitled "Burn Out of General Practitioners: which prevention, which solutions" whose goal is to make recommendations for the prevention and support of this issue. To measure the real impact of the solutions eventually implemented, we need to create a tool for a regular assessment of the prevalence of this problem in our country.

[Mammotest and breast cancer screening]

Breast cancer screening programmes have been integrated in a systematic way into the public health policies of numerous countries. Breast cancer is indeed one of the (rare) health issues which answers the criteria necessary to organize a screening on a large scale. The different methods of diagnosis and the results of various strategies (based on randomized controlled trials and meta-analysis) are described and compared. This reveals that the Belgian policy in this matter is and remains founded today: a standardized mammotest every 2 years for all women from 50 to 69.

[Conceptualization of the preventive theories]

In front of the explosion of the costs of the curative care, the conceptualization of the preventive theories and methodologies, and the shown efficiency of the actions of prevention, this one acquires with evolving time a growing importance and a development desired with the eyes of the doctors, but also of the patients, policy decision makers and insurers. This article intends to approach and clarify the positive contributions but also the multiple limits of the preventive steps.

Mycophenolate mofetil in patients with systemic lupus erythematosus: a prospective pharmacokinetic study

Few studies have assessed the pharmacokinetics of mycophenolic acid (MPA) in non-transplanted patients treated with mycophenolate mofetil (MMF), and little information is available concerning a concentration-effect relationship between the MPA area under the curve (AUC) and the immunological parameters in patients treated for systemic lupus erythematosus (SLE). We evaluated the variations in pharmacokinetics for MPA in patients with SLE and the relationship between MPA-AUC and markers of disease activity. MPA blood concentrations were measured through enzyme-multiplied immunotechnique (T(0), T(30'), T(1h), T(2h), T(3h) and T(4h)) to determine the MPA AUC(0-4h) in patients treated with MMF since at least 4 weeks for SLE. Clinical examination, biochemical analyses and immunological analyses were performed on the same day. The relationship between MPA exposure and disease activity markers was assessed. A total of 20 patients were included in the study. The diagnosis of SLE had been made 87 +/- 72 months before and patients had been treated with MMF for 31 +/- 30 months. Mean dose of MMF on the day of the study was 1600 +/- 447 mg/day. Mean MPA AUC(0-4h) was 28.4 +/- 13.6 mg h/L, mean dose-normalised AUC(0-4h) was 35.5 +/- 13.8 mg h/L and mean MPA C(0) was 3.1 +/- 2.2 mg/L. There was a high correlation between MPA AUC(0-4h) and MPA C(0), (r = 0.80; P < 0.001). AUC(0-4h) tended to be lower in patients who had low complement C3 concentration (<0.67 g/L) and low complement C4 concentration (<0.14 g/L). Moreover, there was a significant relationship between MPA trough levels and complement C4 concentrations (P = 0.043). We confirmed high inter-individual variability of MPA AUC in patients treated with MMF for SLE. This suggests that MPA exposure may be unpredictable with a fixed MMF dose. There was a concentration-effect relationship between MPA exposure (C(0)) and immunological disease activity parameters.

Treatment-dependent loss of polyfunctional CD8+ T-cell responses in HIV-infected kidney transplant recipients is associated with herpesvirus reactivation

Antiretroviral-therapy has dramatically changed the course of HIV infection and HIV-infected (HIV(+)) individuals are becoming more frequently eligible for solid-organ transplantation. However, only scarce data are available on how immunosuppressive (IS) strategies relate to transplantation outcome and immune function. We determined the impact of transplantation and immune-depleting treatment on CD4+ T-cell counts, HIV-, EBV-, and Cytomegalovirus (CMV)-viral loads and virus-specific T-cell immunity in a 1-year prospective cohort of 27 HIV(+) kidney transplant recipients. While the results show an increasing breadth and magnitude of the herpesvirus-specific cytotoxic T-cell (CTL) response over-time, they also revealed a significant depletion of polyfunctional virus-specific CTL in individuals receiving thymoglobulin as a lymphocyte-depleting treatment. The disappearance of polyfunctional CTL was accompanied by virologic EBV-reactivation events, directly linking the absence of specific polyfunctional CTL to viral reactivation. The data provide first insights into the immune-reserve in HIV+ infected transplant recipients and highlight new immunological effects of thymoglobulin treatment. Long-term studies will be needed to assess the clinical risk associated with thymoglobulin treatment, in particular with regards to EBV-associated lymphoproliferative diseases.

[The follow-up of pregnancy by the general practitioner]

After leaving the practice and the topic of family medicine, the follow-up of the non complicated pregnancies slowly reinstates them for multiple reasons: relative shortage obstetricians and gynecologists, redefinition of the roles and missions of the primary care level in a coherent and organized health system, will of demedicalisation and despecialisation of the current health issues. A quality prenatal care of the expectant mothers requires the knowledge of the recommendations in force in this field. This article gives a comprehensive outline of it, starting from an approach "evidence-based medicine " of the scientific literature.

Early pulse pressure and low-grade proteinuria as independent long-term risk factors for new-onset diabetes mellitus after kidney transplantation

Risk factors for new-onset diabetes after transplantation (NODAT) need to be assessed in large cohorts. We retrospectively evaluated the impact of early (3 and 6 months after transplantation) proteinuria, urinary albumin excretion (UAE) and arterial pressure on NODAT in 828 Caucasian renal transplant recipients (median follow-up: 5.3 years; 5832 patient-years). The 10- and 20-year incidence of NODAT was 15.0% and 22.0%, respectively. Low-grade (<1 g/day) (HR: 2.04 [1.25-3.33], p = 0.0042) and very low-grade (<0.3 g/day) (HR: 2.21 [1.32-3.70], p = 0.0025) proteinuria were independent risk factors for NODAT. There was a dose-dependent relationship across UAE categories (increasing risk from normoalbuminuria to macroalbuminuria) with NODAT. Tacrolimus, sirolimus and beta-blockers (HR: 1.86 [1.07-3.22], p = 0.0277) were significantly associated with NODAT even after multiple adjustments, but not diuretics, angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers. Systolic arterial pressure (HR per 10 mmHg: 1.16 [1.03-1.29], p = 0.0126) and pulse pressure (HR: 1.26 [1.12-1.43], p = 0.0002) were associated with NODAT. Only pulse pressure remained significant after adjustments. Patients at highest risks had early proteinuria and pulse pressure >60 mmHg. Early low-grade proteinuria and pulse pressure (in addition to beta-blockers) constitute independent risk factors for NODAT; they may be markers of the metabolic syndrome and/or vascular damage in renal transplant recipients.

[Mammotest and breast cancer screening]

Breast cancer screening programmes have been integrated in a systematic way into the public health policies of numerous countries. Breast cancer is indeed one of the (rare) health issues which answers the criteria necessary to organize a screening on a large scale. The different methods of diagnosis and the results of various strategies (based on randomized controlled trials and meta-analysis) are described and compared. This reveals that the Belgian policy in this matter is and remains founded today: a standardized mammotest every 2 years for all women from 50 to 69.

[Decision-making and end of life care]

Taboos surrounding the end of life and death slowly diminish. People talk more and more about when and how they want or do not want to die, and of what will become of their body after their passing. General practitioners usually accompany their patients in illness and health, but also when death comes near. It is expected from them that, within their relationship to their patients, they create the opportunity to address the patients' last wishes and possibly to formalize them. Three laws as well as the Deontology Code of the Medical Order mention the issue of the last wishes. What comes out is that for the general practitioner, the situation is not always transparent. This article seeks to clarify the definitions (juridical), their perceptions and respect. Furthermore, a proposal that is fully in the spirit of the law is made to simplify current procedures relating to anticipated statements about end of life's wishes.

Antidepressants for non-specific low back pain

BACKGROUND

Antidepressants are commonly used in the management of low-back pain. However, their use is controversial.

OBJECTIVES

The aim of this review was to determine whether antidepressants are more effective than placebo for the treatment of non-specific low-back pain.

SEARCH STRATEGY

Randomised controlled trials were identified from MEDLINE and EMBASE (to September 2007), PsycINFO to June 2006, the Cochrane Central Register of Controlled Trials 2006, issue 2, and previous systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials that compared antidepressant medication and placebo for patients with non-specific low-back pain, and used at least one clinically relevant outcome measure.

DATA COLLECTION AND ANALYSIS

Two blinded review authors independently extracted data and assessed the methodological quality of the trials. Meta-analyses were used to examine the effect of antidepressants on pain, depression and function, and the effect of antidepressant type on pain. To account for studies that could not be pooled, additional qualitative analyses were performed using the levels of evidence recommended by the Cochrane Back Review Group.

MAIN RESULTS

Ten trials that compared antidepressants with placebo were included in this review. The pooled analyses showed no difference in pain relief (six trials; standardized mean difference (SMD) -0.06 (95% confidence interval (CI) -0.28 to 0.16)) or depression (two trials; SMD 0.06 (95% CI -0.29 to 0.40)) between antidepressant and placebo treatments. The qualitative analyses found conflicting evidence on the effect of antidepressants on pain intensity in chronic low-back pain, and no clear evidence that antidepressants reduce depression in chronic low-back pain patients. Two pooled analyses showed no difference in pain relief between different types of antidepressants and placebo. Our findings were not altered by the sensitivity analyses which varied the level of methodological quality required for inclusion in the meta-analyses to allow data from additional trials to be examined. Two additional trials were identified in September 2007 and await assessment.

AUTHORS' CONCLUSIONS

There is no clear evidence that antidepressants are more effective than placebo in the management of patients with chronic low-back pain. These findings do not imply that severely depressed patients with back pain should not be treated with antidepressants; furthermore, there is evidence for their use in other forms of chronic pain.

Potential population impact of the UK government strategy for reducing the burden of coronary heart disease in England: comparing primary and secondary prevention strategies

OBJECTIVE

To use population impact measures to help prioritise the National Service Framework (NSF) strategies recommended by the UK government for reducing the population burden of coronary heart disease (CHD).

DESIGN

Modelling study.

SETTING

Primary care.

DATA SOURCES

Published data on incidence, baseline risk and prevalence of risk factors for CHD and the proportion treated, eligible for treatment, and adhering to the different interventions. Data from meta-analyses and systematic reviews for relative risk and relative risk reduction associated with different risk factors and interventions.

MAIN OUTCOME MEASURES

Population impact measures for the decline in the prevalence of a risk factor and the increased uptake of interventions expressed as number of CHD events prevented in the population.

RESULTS

If lifestyle targets for primary prevention are met, 73 522 (95% CI 54,117 to 95,826) CHD events would be prevented per year, with the greatest gain coming from reduced cholesterol and blood pressure levels. In those at high risk of developing CHD, achieving target levels for lifestyle interventions would prevent 4410 (95% CI 1993 to 8014) CHD events and for pharmacological treatments 2008 (95% CI 790 to 3627) CHD events. For patients with established CHD, achieving NSF targets will result in the prevention of 3067 (95% CI 1572 to 5878) CHD events through improved drug treatment and 1103 (95% CI 179 to 2097) events through lifestyle interventions.

CONCLUSION

Current strategies focus largely on secondary prevention, but many more cardiovascular events would be prevented by meeting the government's public health and primary prevention targets than targeting people at high risk or those with established heart disease.

[Critical reading and EBM : the LIFE trial]

For ten years, " evidence-based medicine " gradually invaded all the medical field : clinical practice but also research and teaching. More than being just a new paradigm, it constitutes one of the pillars of good medical practice beside experimentation, ethics and the requests of the patient. It gathers collective quantitative aspects (statistics, public health, epidemiology, biomedical research) applied to the individual reality of each patient in search of care. One of the methods used in " evidence-based medicine " is critical reading : in-depth analysis of the published trials in medical journals, to extract and validate the elements applicable to the daily clinical practice. The LIFE trial, designed to compare treatment with a sartan or a beta-blocker for hypertensive patients with left ventricular hypertrophy, is used as a model to concretely explicit the various steps and methodologies of critical reading.

[Decision-making processes and medical care at the end of life]

The Federal Authority, the Ministry of Public Health and Environment, charged the Ghent University and the Brussels Free University to produce a continuous recording tool of data's concerning the decision-making processes and the medical care at the end of life, after defining the present state of the art. This tool is built up from a glossary and a questionnaire made up of closed questions with a prospective part and a retrospective part, and leaving the possibility of comments. This questionnaire, first submit to experts and two ethic committees, was sent anonymously to a broad sample of doctors of which 193 answered. This study brings out important information on the application of the laws on palliative care, on the rights of the patient and on euthanasia; it would be advisable to organise in the future a further systematic recording of the end of life conditions throughout a standardized questionnaire whose first version is presented here.

[Evaluation of the vaccine coverage of the general practitioners in the French Community]

The present inter-University study aims to analyze the vaccine statute of the Belgian French-speaking general practionners and the reasons of their possible non-vaccination. A questionnaire with an exhaustive list of vaccines was sent by postal way to a random sample of thousand two hundred and twenty general practitioners. The results were analyzed via SPSS 13. The rate of answer is 60.83%. Two thirds of the doctors (67%) considered themselves in order of vaccination anti-influenza. A majority of doctors (59.7%) is vaccinated systematically each year. The majority of the doctors (83%) considered themselves in antitetanus order of vaccination. Two thirds (67%) think that the vaccine protects from 5 to 10 years. Nearly 73% of the doctors considered themselves in order of vaccination against hepatitis B. More than 50% of the doctors received a vaccine HBV since less than 10 years. The majority of the doctors (79.2%) made a blood control of their protection after vaccination HBV Almost half of the doctors thinks that the vaccine protect for life, 23% from 10 to 20 years and 14% from 5 to 10 years. Two thirds (67%) of the doctors did not make a vaccine against rubella. In 80% of the cases vaccination dated from more than 20 years. In nearly two thirds of the cases the doctors did not make blood control of their protection. Nearly 60% of the questioned doctors think that vaccination offers a protection to life. About half of the doctors did not consider themselves in order of vaccination against the whooping-cough. In three quarter of the cases last vaccination dated from more than 20 years. The two principal durations of protection of the vaccine are with life and between 10 and 20 years. Three quarters of the questioned doctors are considered in order of vaccination against the poliomyelitis. However in 62% of the cases the last vaccine goes up with more than 20 years. More two thirds of the doctors think than the vaccine protects with life or from 10 to 20 years. Two thirds of doctors considered themselves in order of vaccination against the diphteria. For a third of the doctors the vaccine dated from less than 5 years, in more than one quarter of the cases to more than 20 years like between 5 and 10 years. About half of the doctors said they were vaccinated against other pathologies: hepatitis A (34.5%), the yellow fever (21.1%), the thyphoid fever (12.5%), the BCG (8.9%), the pneumococcus (6.6%), meningitis and variola (5%). In the French Community, the vaccine coverage of the general practitioners against the influenza (67%), tetanus (83%) and hepatitis B (73%) is, in this study, higher or equal to the other Belgian and international studies but remains insufficient. A bad vaccine coverage is observed concerning rubella, the whooping-cough, the poliomyelitis. The answers over the durations of protection of the vaccines are rather disparate and show a bad knowledge of these durations and diagrams of vaccination. An update of this knowledge could be carried out during the continuous medical trainings.

[Study of the follow-up by the general practitioner of the children of separated parents]

In Belgium, on 10 millions of inhabitants, there are more than 31.000 divorces per year and we estimate that 600.000 children are experiencing separation of their parents. The general practitioner (GP) have inevitably the responsability of the medical follow-up of some of these children. The possible professional implications related to these young patients, concerning the GP have never been the subject of a study so far. Consequently the aim of this research was to reveal what is happening in the daily practice of the family practitioner related with the children of separete parents. There were some hypothesis notably about particular working conditions for the GP in connection with possible consequences for these children and possible necessity of special professional attitudes. A qualitative research in focus group was organized with GPs in order to get an interaction between the participants and to go past the concepts supposed before the study. Therefore between September and December 04, 8 focus groups of 10-18 generalist practitioners were set up in Brussels and Mons. Each meeting was axed around couples separated for less than 3 years and children between 0 and 15 years. Finally, 120 GPs discussed about 242 cases of divorces from their practice. The debates totally typed word by word were analysed with assistance of the software QSR N5. The point of view of the GPs is: 1) A divorce affects the working conditions of the general practitioner, for example the parcelling out of the medical follow-up of the child and the fact " of being used" by the family. 2) The conflict between the parents after the separation increases the difficulties for the GP in his daily practice. 3) The parental's separation influences the choice of professional attitudes of the GP, notably vis-a-vis the conflict (for instance to try or not to try the conflict's management). 4) Mainly in conflict situation, parental divorce is a risk for the child; psychological or behavioural disorders, physical health problems, school difficulties, ... 5) Certain professional attitudes of the general practitioner can influence positively the evolution of these children, for example to speak to the two parents. 6) Some professional actions aggravate the situation of the these children, for instance to product certain official written documents (attestations, reports, certificats, ...) in a conflicts context. In conclusion, this study desmonstrates that parental separation affects the medical follow-up of the children by the GPs and that professional attitudes influences positively or negatively the child's evolution. For the first time, some negative consequences of the divorce on children are described in the first line. All this results must be confirmed by quantitative research work.

Population impact of stricter adherence to recommendations for pharmacological and lifestyle interventions over one year in patients with coronary heart disease

STUDY OBJECTIVE

To assess the potential number of lives saved associated with the full implementation of aspects of the National Service Framework (NSF) for coronary heart disease (CHD) in England using recently developed population impact measures.

DESIGN

Modelling study.

SETTING

Primary care.

DATA SOURCES

Published data on prevalence of acute myocardial infarction and heart failure, baseline risk of mortality, the relative risk reduction associated with different interventions and the proportion treated, eligible for treatment and adhering to each intervention.

MAIN RESULTS

Adopting the NSF recommendations for pharmacological interventions would prevent an extra 1027 (95% CI 418 to 1994) deaths in post-acute myocardial infarction (AMI) patients and an extra 37 899 (95% CI 25 690 to 52 503) deaths in heart failure patients in the first year after diagnosis. Lifestyle based interventions would prevent an extra 848 (95% CI 71 to 1 614) deaths in post-AMI patients and an extra 7249 (95% CI 995 to 16 696) deaths in heart failure patients.

CONCLUSIONS

Moving from current to "best" practice as recommended in the NSF will have a much greater impact on one year mortality rates among heart failure patients compared with post-AMI patients. Meeting pharmacological based recommendations for heart failure patients will prevent more deaths than meeting lifestyle based recommendations. Population impact numbers can help communicate the impact on a population of the implementation of guidelines and, when created using local data, could help policy makers assess the local impact of implementing a range of health care targets.

Exercise prevention of unloading-induced bone and muscle loss in adult mice

Skeletal unloading causes bone and muscle loss that may be reversed by post-unloading exercise. This study examines the effects of unloading and exercise, using tail-suspension for 14 days combined with a week of post-suspension cage wheel running in mice. Twenty-four adult, male, C57BL/6J mice were divided into four groups (n = 6 mice/group); unsuspended non-running, tail-suspended non-running, unsuspended running, and tail-suspended running. At sacrifice, the calf (soleus, gastrocnemeius and plantaris complex), heart, tibia and femur were collected and weighed. The femora and tibiae were cleaned of non-osseous tissue, subjected to 3-point bending (femurs only), and weighed for dry (105 degrees C; 24h) and ash mass (800 degrees C; 24h). The mean calf mass from the tail-suspended groups (157.13 +/- 2.83 mg) was significantly less than in the unsuspended groups (167.33 +/- 2.83 mg; p = 0.019), with no significant effect of cage wheel running. The mean heart mass in running groups (166.58 +/- 4.78 mg) was significantly greater than the non-running groups (148.17 +/- 4.78 mg; p = 0.013), with no effect of hindlimb suspension. The mean femur ash mass from tail-suspended groups (24.02 +/- 0.38 mg) were significantly less than the unsuspended groups (25.11 +/- 0.34 mg; p = 0.050), and the running groups (25.13 +/- 0.38 mg) were significantly greater than the non-running groups (24.00 +/- 0.34 mg; p = 0.043). No effect was observed for the femur dry mass or percent mineralization. Measurements of mechanical length tended to be lower in tail-suspension, with no significant affects do to cage wheel running. This study suggests that tail-suspension in adult mice significantly decreases skeletal muscle and bone mass, with no change in percent mineralization. Furthermore, one week of running does not reverse the effects on the skeletal muscle and bone mass.

[The setting in observation: management in general medicine]

The law of June 26, 1990 (protection measure of the mental patients) has replaced the old law of collocation of 1850 (review in 1873). Conceived in the line of the principles of the European Convention of the Humans right, it constitutes an important reform of the involuntary treatment of the mental patients and recalls, without any doubt, that the patient is prone of right. The article describes the scope of application of the law of June 26, 1990, and the methods of initiation of a protection measure. Then, the measure in a hospital environment (ordinary procedure and urgent procedure), as well as the measure in a family environment are approached in their waning. Furthermore, the role of the general practitioner is evoked at the various stages of the procedure.

Will changes in primary care improve health outcomes? Modelling the impact of financial incentives introduced to improve quality of care in the UK

OBJECTIVES

To estimate the total health gain from improving the quality of care among patients with cardiovascular disease in line with the quality indicator targets in the new contract for general practitioners (GPs) in the UK.

DESIGN

Statistical modelling, applying population impact measures to estimate cardiovascular health gains from achieving treatment targets in the GP contract, taking into account current levels of treatment and control.

MAIN OUTCOME MEASURES

Number of events prevented in the population over 5 years applied to a national general practice population of 10,000.

RESULTS

The greatest health gain in those aged 45-84 years would come from reaching cholesterol reduction targets. This could prevent 15 events in people with coronary heart disease, seven events in those with a history of stroke, and seven events in those with diabetes. Achieving blood pressure control targets in hypertensive patients without the above conditions could prevent 15 cardiovascular events, with further benefits from reducing blood pressure in patients with high blood pressure and coronary heart disease, stroke, or diabetes. Achieving other targets would have smaller impacts because high levels of care are already being achieved or because of the low prevalence of conditions or associated event risk.

CONCLUSION

It is possible to quantify the health gain to a practice population of achieving quality targets such as those set in the new GP contract. The amount of health gain is sensitive to current quality of care, prevalence of conditions, and risk factors, and to the size of change anticipated. Nevertheless, it appears that significant health gains could result from achieving the proposed quality targets.

Will changes in primary care improve health outcomes? Modelling the impact of financial incentives introduced to improve quality of care in the UK

OBJECTIVES

To estimate the total health gain from improving the quality of care among patients with cardiovascular disease in line with the quality indicator targets in the new contract for general practitioners (GPs) in the UK.

DESIGN

Statistical modelling, applying population impact measures to estimate cardiovascular health gains from achieving treatment targets in the GP contract, taking into account current levels of treatment and control.

MAIN OUTCOME MEASURES

Number of events prevented in the population over 5 years applied to a national general practice population of 10,000.

RESULTS

The greatest health gain in those aged 45-84 years would come from reaching cholesterol reduction targets. This could prevent 15 events in people with coronary heart disease, seven events in those with a history of stroke, and seven events in those with diabetes. Achieving blood pressure control targets in hypertensive patients without the above conditions could prevent 15 cardiovascular events, with further benefits from reducing blood pressure in patients with high blood pressure and coronary heart disease, stroke, or diabetes. Achieving other targets would have smaller impacts because high levels of care are already being achieved or because of the low prevalence of conditions or associated event risk.

CONCLUSION

It is possible to quantify the health gain to a practice population of achieving quality targets such as those set in the new GP contract. The amount of health gain is sensitive to current quality of care, prevalence of conditions, and risk factors, and to the size of change anticipated. Nevertheless, it appears that significant health gains could result from achieving the proposed quality targets.