Primary Care Situations Research Articles

Primary health care situations in remote rural villages of the Savannakhet province, Lao People’s Democratic Republic

BackgroundTo improve the health of the rural population in the Lao People’s Democratic Republic (Lao PDR), the government has emphasized a primary health care approach in the Health Sector Reform Strategy by 2025. The objective of the present study was to describe the health-related situations of remote rural villages of the Lao PDR to inform strategies for promoting primary health care in such villages.MethodsTen remote rural villages were purposively selected from the catchment areas of two health centers in the Xepon district, Savannakhet province. The surveyors collected data by conducting a questionnaire-based interview with village health volunteers and by observing the village environment in 2018. The survey focused on village situations on the eight elements of primary health care (health education; food supply and nutrition; safe water and basic sanitation; maternal and child health care; immunization; prevention and control of locally endemic diseases; treatment of common diseases and injuries; and provision of essential drug).ResultsThe common health problems were diarrhea, followed by malaria, and cough. The identified possible risk factors for the health problems were not washing hands with soap, open defecation, not boiling drinking water, not exclusively breastfeeding, presence of animal feces on the village ground, absence of garbage management system, not using a bed net when sleeping in the forest, and exposure to indoor cooking and tobacco smoke. In many villages, villagers were not able to eat enough food and did not eat protein-rich food and vegetables daily.ConclusionsPotential risk factors for the reported common health problems were often prevalent in the study villages. Villagers can address most of these risk factors, as interventions to address such risk factors do not require a large financial input. There is a need for intersectoral actions between the health and other sectors to address food shortages and indoor air pollution due to indoor cooking using biomass fuel.

ПЕРВИЧНОЕ ЗВЕНО ЗДРАВООХРАНЕНИЯ – ИСТОРИЯ, ЭТАПЫ, МОДЕРНИЗАЦИЯ

Annotation: The article provides an overview of the main guidance documents and literature sources on the process of providing primary health care to residents of the Russian Federation. The historical background of the formation of the processes providing primary care is given, revealing the interdependence of measures in the field of healthcare reform, the introduction of new norms and rules for the provision of services to the population within the framework of primary health care. Primary health care is the foundation of the entire process of providing medical care, which includes measures for the prevention, diagnosis, treatment of diseases and conditions, medical rehabilitation, monitoring the course of pregnancy, the formation of a healthy lifestyle and sanitary and hygienic education of the population. It is the position and condition of the primary health care system that largely determine the health indicators of the nation, the level of satisfaction of the population and, as a result, reflect the results of the functioning of the medical industry as a whole. Along with a significant contribution to the health of each person, the primary link, as a rule, is the place of “first contact” with the healthcare system, forming the opinion of our citizens about the industry as a whole and the possibility of exercising their constitutional rights to receive medical care. A strong primary link prolongs a “healthy” life, reduces mortality, and forms people’s commitment to a healthy lifestyle. On the basis of the historically established situation of primary health care in Russia (changes in the structure of demographic indicators, economic and social conditions), a line of problematic and urgent issues in the provision of medical care in the structure of primary health care is traced — depreciation of fixed assets of polyclinic and hospital buildings, dilapidated or, often, the lack of necessary medical equipment; lack of motor transport in district hospitals, including paramedic-obstetric centers and outpatient clinics providing medical care to the rural population; the problem of staffing and wages of employees of medical organizations that do not meet demand. As a result of the above, there is a need to find new systemic approaches to addressing issues of accessibility and improving the quality of primary health care, the development of new organizational and functional models of primary care, which as a result should lead to an increase in life expectancy and the achievement of national goals.

Telemedicine in Primary Care: Qualitative Work Towards a Framework for Appropriate Use.

Telemedicine has been implemented in many health systems by necessity, yet evidence is sparse about its appropriate use for the delivery of primary care. We sought to understand what clinicians and patients consider to be appropriate use of telemedicine in primary care to inform future development of a framework that should be valuable to diverse stakeholders. We conducted in-depth, structured interviews of patients, clinicians who deliver primary care, and other select informants. They were asked to discuss optimal, acceptable, and suboptimal uses of telemedicine for delivering care relative to in-person care delivery. Audio was transcribed and paired reviewers analyzed the content to identify the key concepts that motivated the informants. The reviewers did thematic analysis to organize the concepts into unifying themes. Our 18 key informants generated 103 unique concepts. The unique concepts aggregated into themes suggesting the clinical situations in which telemedicine is appropriately used in primary care and clinical situations in which it should be avoided. We also learned of motivators toward expanded, or at least continued, use of telemedicine and motivators away from telemedicine's continued use. The informants expressed their expectations regarding decision making about telemedicine use and who should make these decisions. These key concepts and themes are expected to be a valuable starting point for the development of a framework to inform appropriate use of telemedicine in primary care.

Management of drug-drug interactions with nirmatrelvir/ritonavir in patients treated for Covid-19: Guidelines from the French Society of Pharmacology and Therapeutics (SFPT)

ObjectivesNirmatrelvir in association with ritonavir (PAXLOVID™, Pfizer) is an antiviral agent targeting the 3-chymotrypsin–like cysteine protease enzyme (3C-like protease or Mpro) which is a key enzyme of the viral cycle of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This combination with a well-known pharmacokinetic enhancer leads to a high risk for drug-drug interactions in a polymedicated elected population for treatment. The aim of this work was to provide recommendations on behalf of the national French society of pharmacology (French Society of Pharmacology and Therapeutics; SFPT), by suggesting optimal and pragmatic therapeutic strategies if nirmatrelvir/ritonavir is to be given together with drugs commonly used, in order to ensure secured physicians’ prescription.MethodsSix clinical pharmacologists search the scientific literature to provide a first draft of recommendations. Thereafter, twelve other clinical pharmacologists verified the recommendations and proposed modifications. The final draft was then validated by all 18 participants.ResultsFive distinct recommendations were issued: i) contra-indications, ii) “PAXLOVID™ not recommended with the comedication”, iii) “PAXLOVID™ possible whether the comedication is discontinued”, iv) “PAXLOVID™ possible only after an expert advice” and v) “PAXLOVID™ possible without modification of the associated treatment”. The final document comprises recommendations for 171 drugs/therapeutic classes aiming to secure prescription. In complex situations, clinicians are advised to contact their pharmacology department to obtain specific recommendations on the management of drug-drug interactions with nirmatrelvir/ritonavir.ConclusionThese recommendations intend to be a help for clinicians willing to prescribe nirmatrelvir/ritonavir and to prevent drug-drug interactions leading to adverse drug reactions or loss of efficacy. They constitute a guideline for primary care situations. Of course, some complex situations may require expert advices and here, again, clinical pharmacologists are at the forefront in providing therapeutic advice.

Type B adverse drug reactions to antibiotics and antibiotic allergy in infants and children.

Distinguishing allergic reactions from non-allergic type B adverse drug reactions (ADRs) to antibiotics is challenging, particularly in children, because we lack epidemiological information that can be used in primary care situations. This study aimed to investigate the characteristics of type B ADRs to antibiotics and antibiotic allergy (AA) in previously healthy children. This was a retrospective cohort study of previously healthy children admitted for treating urinary tract infections over a 10 year period. The primary outcome was the frequency of type B ADRs and AAs that were assessed by pediatricians. Secondary outcomes include demographic data about patients' backgrounds, infections, treatments, ADRs, and action against ADRs. All the data were collected via patients' medical records. Out of 791 participants, type B ADRs were reported in 77 children (9.7%), and AA labeling was performed in six children (0.8%). Physicians assessed 30.4% of type B ADRs as severe or life-threatening symptoms. All patients were discharged without long-term complications. Physicians detected the primary cause (individual patient host factors or environmental risks) in 39 cases of type B ADRs. Type B ADRs to antibiotics were frequently reported even in previously healthy children. Physicians should use appropriate techniques (e.g., specialist consulting and skin testing) when they suspect that a type B ADR might be an AA. Labeling and de-labeling programs and tools for type B ADRs related to antibiotics should be implemented to prevent the mislabeling of AA.

Educational film on the geriatric basic assessment in primary care-Methods of cinematic authenticity

The relevance of care of older persons in general practice requires the conveyance of procedural and conditional knowledge of the geriatric basic assessment (GBA) even during medical studies. There is aneed for action with respect to student knowledge on specific problems of older patients. This paper describes how the primary care situation can be made tangible for students based on afilm project at the Hannover Medical School (MHH). During film production, strategies for creating authenticity were applied using cinematic means. The film is used in the teaching module of family medicine at MHH. Student evaluation investigated whether the educational film provided an emotional experience and whether the presentation mode of the GBA was perceived as authentic. The majority of students were emotionally touched by the film. The educational film was successful in conveying the complexity of care of older people and in presenting the special role of family physicians in geriatric care. The students recognized the necessity of the GBA and found the representation predominantly realistic; however, individual cinematic reception and previous experiences also influence the perception of the cinematic form with respect to the representation of reality. This method might improve the conveyance of authenticity in educational videos in medicine.

Which strategies might improve local primary healthcare in Germany? An explorative study from a local government point of view

BackgroundFacing rising inequities and poorer accessibility of physicians in rural areas, new healthcare delivery structures are being considered to support local healthcare in German communities. To better understand perspectives on and attitudes towards different supplementary models, we examined attitudes among local politicians in the German federal state of Lower Saxony towards the suitability of supplementary care models.MethodsAs part of a cross-sectional study, we surveyed local politicians in Lower Saxony at the local authority and district levels (n = 449) by mail questionnaire. We asked for an assessment of four potential supplementary healthcare models at the local level: the use of trained medical assistants, patients’ buses, mobile physicians’ offices, and telemedicine.ResultsThe response rate was 71.0% for mayors (n = 292) and 81.6% (n = 31) for county administrators. In summary, 72.4% of respondents supported the use of trained medical assistants, 48.9% voted for patients’ buses, 22.0% for mobile physicians’ offices, and 13.9% for telemedicine. Except for telemedicine, the politicians’ approval of the supplementary models in rural areas was higher than in urban areas. The assessment regarding the suitability of each model was not significantly connected with indicators of a positively or negatively assessed local healthcare situation. The analyses showed that the use of trained medical assistants was associated with the positive effects of division of labor and potential to relieve physicians. In contrast, there was skepticism about technical support via telemedicine, mostly due to concerns about its unsuitability for elderly people and the potential lower quality of healthcare delivery.ConclusionLocal politicians widely accept the use of trained medical assistants, whereas the applicability of technical solutions such as telemedicine is perceived with skepticism. Therefore, the knowledge gap between evidence for and prejudices against telemedicine needs to be addressed more effectively. Reasons for the assessments of the presented models are more likely traceable to personal views than to assessments of the actual estimated local primary care situation.

Usability Evaluations of Health Institutions Inspection Software

Dissatisfaction with health services is increasing year by year and health appears to be the worst area assessed by population. Technological innovation, such as the use of information technology and communication tools and computerization of processes, can assist in the implementation of technological resources that enable the improvement of health services. A solution developed primarily for the Regional Council of Medicine of Santa Catarina (CRM-SC) and then expanded to the Federal Council of Medicine (CFM) - which is currently being used by all regional councils - is CRVirtual, a system that supports the activities undertaken by councils to assist in the health facilities inspection process. The system allows the inspection and monitoring of inspections carried out in hospitals, clinics, health centers among others, enabling verify which of these establishments are infringing the laws, resolutions and decrees enforced for good services to the population. This study aims to verify the improvement points in the system interface so that the survey carried out by agents and inspection doctors can be done with more quality in order to facilitate the monitoring of the inspection process and assessment notice the establishments where irregularities were detected. Empirical methods (with the participation of the system users) and not empirical (without the users participation) for the CRVirtual interface evaluation were: Heuristic evaluation and Usability Testing. It was identified 27 points of improvement in the system interface. The observed users' speeches and actions analysis, as well as the application of usability tests, showed that the system is relatively easy to be used and to learn through. Some difficulties faced have been identified, but users feel motivated to use the system and recognize its usefulness as an inspections registration facilitator and when monitoring processes, in addition to providing more flexibility to the establishments inspection process. After correcting these detected points, the system was used by agents and inspection doctors during the year 2014. The result of these inspections was an unprecedented survey of primary care situation in Brazil, where the 952 health facilities visited, CFM concluded, after analysis of data obtained through the CRVirtual, that the situation is worrying in all aspects.

Primary care at Swiss universities--current state and perspective.

BackgroundThere is increasing evidence that a strong primary care is a cornerstone of an efficient health care system. But Switzerland is facing a shortage of primary care physicians (PCPs). This pushed the Federal Council of Switzerland to introduce a multifaceted political programme to strengthen the position of primary care, including its academic role. The aim of this paper is to provide a comprehensive overview of the situation of academic primary care at the five Swiss universities by the end of year 2012.ResultsAlthough primary care teaching activities have a long tradition at the five Swiss universities with activities starting in the beginning of the 1980ies; the academic institutes of primary care were only established in recent years (2005 – 2009). Only one of them has an established chair. Human and financial resources vary substantially. At all universities a broad variety of courses and lectures are offered, including teaching in private primary care practices with 1331 PCPs involved. Regarding research, differences among the institutes are tremendous, mainly caused by entirely different human resources and skills.ConclusionSo far, the activities of the existing institutes at the Swiss Universities are mainly focused on teaching. However, for a complete academic institutionalization as well as an increased acceptance and attractiveness, more research activities are needed. In addition to an adequate basic funding of research positions, competitive research grants have to be created to establish a specialty-specific research culture.

Utilization of Norway’s Emergency Wards: The Second 5 Years after the Introduction of the Patient List System

Utilization of services is an important indicator for estimating access to healthcare. In Norway, the General Practitioner Scheme, a patient list system, was established in 2001 to enable a stable doctor-patient relationship. Although satisfaction with the system is generally high, people often choose a more accessible but inferior solution for routine care: emergency wards. The aim of the article is to investigate contact patterns in primary health care situations for the total population in urban and remote areas of Norway and for major immigrant groups in Oslo. The primary regression model had a cross-sectional study design analyzing 2,609,107 consultations in representative municipalities across Norway, estimating the probability of choosing the emergency ward in substitution to a general practitioner. In a second regression model comprising 625,590 consultations in Oslo, we calculated this likelihood for immigrants from the 14 largest groups. We noted substantial differences in emergency ward utilization between ethnic Norwegians both in rural and remote areas and among the various immigrant groups residing in Oslo. Oslo utilization of emergency ward services for the whole population declined, and so did this use among all immigrant groups after 2009. Other municipalities, while overwhelmingly ethnically Norwegian, showed diverse patterns including an increase in some and a decrease in others, results which we were unable to explain.

A Better Way to Know What Patients Believe and Value about Health

In every medical school, residency training, and professional society, there is a push for doctors to practice “patient-centered” medicine. A central tenet of patient-centered medicine is that the patient’s values and beliefs guide the treatment. But what does that really mean? And how are doctors, who face increasing time pressure, supposed to know what a patient believes and values about health? As a primary care doctor, I have been trained from medical school, and onwards, to take a history from patients that mostly focuses on organs and symptoms. The traditional medical history is based on the false idea that health is largely “physical.” However, in a national survey, 30 % of Americans said that health is a mix of emotional, spiritual, mental, and social factors.1 This matters because what patients believe about health has been linked to their willingness to change health behaviors, take medications, and even whether or not the patient’s health improves.2 After many years of patient care and research on patients’ explanatory models of health and disease, I have learned that there is a more effective and efficient way for doctors to understand what a patient believes and values about their health. Here’s how. Start the visit with what I call, ‘The two questions that every medical student and doctor should be asking their patients.’ These two simple questions, developed by health communication experts and used mostly in research settings,1 are: “How is your health,” followed by, “How do you know (or, why do you think that)?” “Hmmmm,”—the patient often says in response, “No one has ever asked me that,” or, “I never really thought about it.” But if I give them just a few seconds, they become fountains of valuable information about what’s making them sick, what keeps them healthy, and what matters most to them about their health. That’s true even for men, who, we know, are less likely than women to see a doctor or to ask questions at the visit. Let me illustrate. When I asked these questions of Carl, one new patient, he said his health was “just okay.” Asked how he knew, Carl said, “Because right now I take high blood pressure medicine. I want to get off the medicine and lose weight. It’s hard because I don’t like running, though I enjoy walking. My weight has been a struggle ever since I was a kid.” For a 47-year-old man, that was a veritable flood of insight. With this information, I could quickly focus on Carl’s priorities. I offered information on the Dietary Approaches to Stop Hypertension (DASH) diet and encouraged him to walk for exercise. I acknowledged his lifelong weight struggles with empathy, becoming his ally. Studies show that when doctors and patients develop a treatment plan as allies, patients benefit far more. The results? Six months later, Carl had lost 11 lb, his blood pressure was lower, and we cut down his medication. Two questions had resulted in better care and a healthier patient. In a recent study, patients reported that patient-centered decision making occurred least often in routine primary care situations, such as being started on blood pressure or lipid-lowering medicines.3 But these routine situations are exactly when these two questions are most helpful, because the answers provide key information on the patient’s values and beliefs—which has to be the starting point for any patient-centered decision making. Here’s another example. Sondra, a 64-year-old woman, answered my first question by saying that her health was “better now, pretty good,” because she had, at last, finished cancer treatment. The treatment caused “bad side effects and depression,” she explained, “but I also had a lot of family support.” Sondra said she knew her health was pretty good because, “my energy is back, and I want to start traveling again.” Our visit focused on keeping her energetic and making sure her depression was controlled, so that she could do the things she felt she missed during cancer treatment. And I had learned that I could involve her family in her care, if I needed—another hallmark of quality health care. Primary care physicians face increasing time pressure and burn-out. These two questions are effective and efficient in helping me crack open the black box of my patients’ lives, beliefs, and values—and they bring me closer to patients, instead of keeping them at a distance. The next time you are with a patient, try asking these two questions. The answers will help you learn what you really need to know about your patients and can help fulfill the promise of patient-centered care.

Corporate Governance, Sustainable Development and Value Creation—Some Evidences From Italian Listed Companies

Modern corporate situations, characterized by the globalisation of the markets and of the information, highlight the need to link the potential of a not transient growth to the adequate reconciliation of all the expectations converging around the entrepreneurial formula and not only of those attributable to shareholders. In such a defined context, corporate governance tends to evolve from a situation of primary care for the expectations of shareholders (shareholder's view) and for the correlated financial responsibility, to a wide consideration of all the stakeholders (stakeholder's view) and related responsibilities (financial, environmental, social, administrative). The correct carrying out of governance processes requires, therefore, a clear focus on sustainable development and on the related assumption of a concept of global responsibility. The decisions made by the governing bodies must be driven by the purpose to create value in the long term according to conditions of fairness and sustainable development. To sum up, this research aims to deepen the existing connections between corporate governance, sustainable development and value creation on the basis of the empirical analysis of a limited number of listed Italian companies afferent to the public utilities sector. The paper, based on a deductive approach, is composed of two distinct but strictly connected parts: the first theoretical and the second empirical. The empirical research consists of a content analysis of the most recent documents (sustainability reports and annual reports) worked out by the selected companies. The results obtained about the degree respect of sustainable development conditions by each company are linked to the related value dimension (social, economic, competitive and environmental performance) aimed at verifying if the assumption of a corporate governance approach inspired by sustainability is susceptible of favouring the company development in a medium long term. From the delivered research it emerges how public utilities that promote behaviours in line with the sustainability conditions are marked out by stable growth paths. Conversely, the companies that assume a vision mainly addressed to the economic dimension, neglecting the other areas are generally compromised in the performance realized.

Swiss Student’s Arguments in Favour and against a Career in Primary Care

Background: Interest in a career in Primary Care has alarmingly waned among medical school graduates in Western countries; the number of Primary Care Physicians (PCP) is clearly insufficient to cover future needs. Qualitative studies in which medical students express their interest in a career in Primary Care are scarce. Objective: To estimate the percentage of medical students planning to start a career in Primary Care, to analyse statements in favour of and against a career in Primary Care given by sixth-year medical students, and to compare these statements with those of younger medical students. Methods: A questionnaire was mailed to sixth-year medical students in 2008, soliciting three answers in favour of and three answers against a career in Primary Care, and the results were qualitatively assessed and compared to the statements of first- to fourth-year medical students attending continuing medical education. In addition, participants indicated whether or not they aspired to become a PCP. Results: A total of 2,502 statements in favour of and against a career in primary care were given by 302 sixth year medical students and 112 first- to fourth-year medical students. The overall response rate was 73.8%. The most frequently occurring positive categories, Experience in Daily Practice and Professional Interactions, accounted for 83% of all positive statements. The most frequently occurring negative category was Working Conditions (24.8%). Of the 414 participants, 59 (14.3%) choose to become a PCP (7.1% of first-to fourth-year students versus 16.9% of sixth- year medical students; p=0.012). The analysis of students' statements detected only few differences between gender, year of study and the interest to become a PCP or not. Conclusions: The given statements assigned to the different categories highlighted the current difficult and uncertain situation of primary care concerning health policy and income. During medical school, the fraction of those planning to go into PC is slightly increasing. Nonetheless, only a small percentage of medical school graduates intend to become a PCP. Therefore, there is an urgent need to increase the attractiveness of primary care by broadening the PCP's professional experience, as well as establishing an assured remuneration appropriate to the individual level of specialisation.

Understanding the prescription of antidepressants: a Qualitative study among French GPs

BackgroundOne-tenth of France's population is prescribed at least one antidepressant, primarily by General Practitioners. The reasons for this high prescription rate remain unclear. One-third of these prescriptions may not comply with clinical practice guidelines, and 20% are potentially unrelated to any psychiatric condition. Our aim was to explore how GPs declare they use antidepressants in daily practice and understand their reasons for prescribing them.MethodSix focus groups including a total of 56 rural and urban GPs, with four interviews were performed. The topic guide focused on reasons for prescribing antidepressants in various primary care situations. Phenomenological analysis was performed by four researchers.ResultsAntidepressants were seen as useful and not harmful. Personal assessment based on experience and feeling determined the GPs' decisions rather than the use of scales. Twenty-four "non-psychiatric" conditions possibly leading to prescription of antidepressants in primary care were found.ConclusionsThe GPs reported prescribing antidepressants for a wide range of conditions other than depression. The GPs' decision making process is difficult and complex. They seemed to prefer to focus on their difficulties in diagnosing depression rather than on useless overtreatment. Instead of using the guidelines criteria to detect potential cases of useful prescription, physicians tend to use their own tools based on gut feelings, knowledge of the patient and contextual issues.

Metals and disease: a global primary health care perspective.

Metals are an important and essential part of our daily lives. Their ubiquitous presence and use has not been without significant consequences. Both industrial and nonindustrial exposures to metals are characterized by a variety of acute and chronic ailments. Underreporting of illnesses related to occupational and environmental exposures to chemicals including metals is of concern and presents a serious challenge. Many primary care workers rarely consider occupational and environmental exposures to chemicals in their clinical evaluation. Their knowledge and training in the evaluation of health problems related to such exposures is inadequate. This paper presents documented research findings from various studies that have examined the relationship between metal exposures and their adverse health effects both in developing and developed countries. Further, it provides some guidance on essential elements of a basic occupational and environmental evaluation to health care workers in primary care situations.

Implementation of evidence based medicine in primary care

The particular situation of primary care - i.e. decentralized setting, comprehensive medical care, and limited access to continuous medical education - makes it difficult to implement evidence-based medicine into daily practice. Therefore, the Institute of General Practice of the Paracelsus University (PMU) in Salzburg and Actavis GmbH Austria developed "REM" (Rechercheservice evidenzbasierte Medizin). This is a web-based enquiry service offered mainly to GPs who can submit questions arising in daily practice which are answered by the service according to current best evidence. In 8.5 months 176 physicians registered to participate. A total of 31 submitted at least one question. In total, REM processed 134 questions. The number of physicians registered and the frequency of enquiries show that REM can facilitate the implementation of evidence-based medicine in primary care. Nonetheless, only a small proportion of the physicians registered actually made use of the service. Improvements are necessary to promote interest in this new way of continuous medical education.

An Interdisciplinary Community Diagnosis Experience in an Undergraduate Medical Curriculum: Development at Ghent University

Since 2002, the medical curriculum at Ghent University has incorporated a community diagnosis exercise, teaming medical students with master of social work and social welfare studies students. The course focuses on the interaction between the individual and the community in matters of health and health care. During one week, small groups of students visit patients and their caregivers in six underserved urban neighborhoods, and they combine these experiences with public health data, to develop a community diagnosis. Local family physicians and social workers monitor sessions. The course requires students to design an intervention tackling one community health issue. At the end of the course, the students present their diagnoses and interventions to community workers and policy makers who provide feedback on the results. In the authors' experience, medical and social work students all value the joint learning experience. The occasional culture clash is an added value. The one-week course is very intensive for students, mentors, and cooperating organizations. Although students criticize time restraints, they feel that they reach the outlined objectives, and they rate the overall experience as very positive. The authors find that this interdisciplinary, community-oriented exercise allows students to appreciate health problems as they occur in society, giving them insight into the interaction of the local community with health and health care agencies. Combining public health data with experiences originating from a patient encounter mimics real-life primary care situations. This campus-community collaboration contributes to the social accountability of the university.

All patients with suspected dementia should be scanned at least once with CT or MRI

Professor Wahlund has made a convincing case that structural imaging is not useful as adjunct investigation for all cases of dementia in the primary care situation. In my opinion, no-one has ever suggested that it would or should be. Indeed, there would be insufficient resources to do so and it would be overkill, to say the least. Primary care is not the setting in which brain imaging should be performed and so I agree with Wahlund in this regard. However, following primary care evaluation of a patient with suspected dementia, a referral to a second line setting often occurs. This can happen for a number of reasons, including the need for treatment, and it is here that imaging should always be performed. The first approach then should always be a structural one, not only to exclude the odd case of a primary glioma or subdural hematoma, but to show evidence of medial temporal lobe atrophy, shown by the Swedish SBU to be of high diagnostic accuracy for AD (SBU, 2006). Additionally, vascular changes may be demonstrated, which may prompt the specific treatment of risk factors, or else focal atrophy suggestive of another specific neurodegenerative disorder may be seen (Scheltens et al., 2002; van der Flier and Scheltens, 2005). The recent surprising observation of a relatively high frequency of microbleeds in AD patients (18%) and VaD patients (65%), which may caution the clinician against the use of oral anticoagulation, again underlines the need to perform MRI in demented patients (Cordonnier et al., 2006). The only exception to this would be the sound judgment of the clinician that no nosological diagnosis is warranted in a specific case (usually because of high age, presence of severe dementia and/or extensive comorbidity). It is important to note that, in the case of medial temporal lobe atrophy, however it is measured, there is a tendency for reduced diagnostic utility (reduced specificity) at a higher age, making age specific norms a requirement (van de Pol et al., 2006).

Evaluation of the WHO Haemoglobin Colour Scale for diagnosis of anaemia in children and pregnant women as used by primary health care nurses and community health workers in western Kenya

To evaluate the diagnostic accuracy of the WHO Haemoglobin Colour Scale (HCS) for anaemia in three groups of children aged 2 months to 2 years (sick children, those visiting an immunization clinic and a community-based random sample of children) and a sample of pregnant women. Finger-prick blood samples were taken from all consenting participants. Haemoglobin (Hb) levels from the HCS were compared with results from a HemoCue portable haemoglobinometer. Sensitivity, specificity and positive and negative predictive values for the HCS were calculated. A total of 457 sick children, 336 children visiting immunization clinics, 454 children from the community at large and 643 pregnant women participated. The prevalence of anaemia (Hb<11 g/dl) in these groups was 87%, 79%, 74% and 52%, respectively. The prevalence of severe anaemia (Hb<7 g/dl) was 24%, 11%, 10% and 2%, respectively. The sensitivity of the HCS for anaemia ranged from 60% to 79% and specificity from 59% to 94%. The sensitivity of the HCS for severe anaemia ranged from 24% to 63% and the specificity from 97% to 100%. Through use of the HCS, the proportion of sick, anaemic children visiting peripheral health facilities diagnosed and treated for anaemia would increase from 3% to 65%. In an area with high prevalence of anaemia among sick children, use of the HCS has the potential to significantly increase the proportion of sick, anaemic children who are diagnosed with anaemia and given appropriate treatment. Further evaluations of the effect of the use of the HCS on treatment practices at the health facility level are required.

The CONTENT project: a problem-oriented, episode-based electronic patient record in primary care

In order to obtain a proper knowledge base in primary care, a form of electronic patient record is needed that takes into account the specific characteristics of the doctor-patient encounter, the patient population, the presentation of diseases and the associated prevalences. However, in real life this has not happened for several reasons. For the most part, existing patient records are determined by invoicing requirements rather than by endeavours to meet the intrinsic needs of primary care. CONTENT (CONTinuous morbidity registration Epidemiologic NeTwork) is an ambitious scientific project in Germany to establish a system for adequate record keeping and analysis in primary care. Based on a classification system designed for the special situation of primary care, a scientific network is being established consisting of participating surgeries, general practitioners, computer scientists and statisticians. The project is supported by the German Federal Ministry of Education and Research. The aims are strictly scientific and the underlying hypothesis is that the knowledge-gaining process can be accelerated by combining the experience of many, especially with respect to complex interactions of factors and the analysis of rare events. Aside from maintaining a morbidity registry, within the CONTENT framework various prospective and retrospective studies on particular epidemiological and health economic research topics will be conducted.