Journal of General Practice

Background: Constipation is a common complaint in the care of elderly in long term care facility. The Bristol Stool Chart (BSC) has been the gold standard for describing the form and consistency of bowel motions but is limited as a descriptive qualitative tool.
Objective: To pilot the feasibility of a novel stool scoring system in quantitative analysis of bowel motions and their texture.
Methods: 100 medical records were randomly selected from a local long-term care facility to extract descriptions of bowel movements and stool textures in the previous 7 days. A novel numeric stool score of +3 to -3 for each documented bowel motion and a cumulative value was obtained. Such score was recorded against the total cost of treatment.
Results: In the period studied, there was no significant difference in the mean bowel motions, the cumulative stool score and costs of laxative treatment between the male and female population.

Bladder injury during cesarean section is associated with significant morbidity. It can lead to prolonged operative time, urinary tract infection and formation of vesico-uterine or vesico-vaginal fistula. Post cesarean pregnancy, presence of abdominal and or bladder adhesions, emergency cesarean section, placenta previa and/or accrete/ increta/percreta, all are significant risk factors for bladder injury during cesarean section. Immediate repair of the bladder injury always yield better result. But the availability of an urologist is not always certain. The obstetrician should better be well conversant with the bladder repair, which is relatively simple technique and can manage the situation effectively.

Background: Leaders play an essential role in the health care of older adults. The leadership role has changed over the years because of new demands in providing care for older adults with multiple chronic conditions, as well as a lack of resources. Aim: The aim of this study was to describe formal leaders’ views over time on their leadership and the competence among staff in care of older adults. Method: Individual interviews and focus group discussions with leaders in care of older adults were conducted with a total of 46 formal leaders in 2000 (n=20) and 2011 (n=26). The analysis took a qualitative approach, using interpretative description. Results: The leaders’ descriptions of leadership encompassed two different views on leadership over time, from “I as a leader” to “We together”. The leaders interviewed in 2011 saw practical wisdom (phronesis) as a central aspect of staff competence. Throughout the interviews, a greater focus on personal characteristics was seen over time. Conclusions: Differences over time in views of the leaders’ role and staff competence, especially the increased focus on personal characteristics, may have an impact on the health care provided to older adults. This is particularly true if formal education is not prioritized. Strategies within organizations and continuing development and education must take these changes into consideration.

One of the challenges of antiretroviral treatments (cART) in HIV is to achieve optimal and persistent adherence. In order to achieve this, electronic pill-boxes used in conjunction with motivational interviewing have shown promising results in monitoring and improving patient’s adherence to treatments. This study reports a case where the patient was opening every day on time his pill-box to discard systematically the tablets in order to hide consciously his nonadherence. A too regular pattern in drug intake according to the electronic pill-box should alert health professionals for the potential risk of distorted adherence results.

Introduction: Groin hernias comprise a large proportion of the surgical volume, worldwide. Inguinal hernia repair is possibly the commonest general surgical procedure. In recent years, greater focus has been put on the quality-of-life of the patient, using postoperative pain as an indicator. Iliohypogastric neurectomy has been shown to significantly reduce postoperative pain. It was considered necessary to evaluate the effectiveness of iliohypogastric neurectomy in day surgery at a tertiary hospital, in a low income country. A study to compare the short-term and medium-term postoperative pain following Lichtenstein hernia repair, with and without iliohypogastric neurectomy, was conducted. Methods: It was a double-blinded randomized parallel clinical trial. A total of 96 patients, out of 106 eligible patients, with primary inguinal hernias were recruited in Mulago National Teaching and Referral Hospital’s Surgical Outpatient Department, Kampala, Uganda. Participants were randomized into either a standard Lichtenstein repair group (46 patients) or a standard Lichtenstein repair with iliohypogastric neurectomy group (50 patients), and underwent day surgery. The participants and outcome assessors were blinded to the treatment method. Outcome variables were postoperative mean pain scores at rest and following activity. Pain assessment was done with the Visual Analogue Scale at different time intervals; 2 hrs, 7 days and 28 days postoperative. Results: There was a significant difference in mean pain scores between the standard. Lichtenstein repair (0.957) and the Lichtenstein repair with iliohypogastric neurectomy (0.34) groups (P<0.001). There was less taskinduced pain in the Lichtenstein repair with iliohypogastric neurectomy group (0.140) compared to the standard Lichtenstein repair group (0.739) (P<0.001). Conclusion: Postoperative pain in Lichtenstein repair with iliohypogastric neurectomy is less in comparison to Lichtenstein repair alone, in the treatment of inguinal hernias. Iliohypogastric neurectomy is thus an effective method of controlling postoperative pain in Lichtenstein hernia repair.

Introduction: The Ankle-Brachial Index measurement (ABI) is an easily performed bedside test used to screen for lower extremity arterial injury. It is possible that the ABI is not always correctly performed in the acute setting, depending on available equipment and provider familiarity with validated measurement techniques. We sought to determine the potential for false positive ABI results in healthy subjects if the ABI is performed incorrectly. We also sought to identify the method most likely to minimize false positive results. Materials and methods: Healthy volunteers and low acuity emergency department patients were enrolled. Exclusion criteria included a known history of documented peripheral arterial disease or extremity trauma. Subjects were examined by two investigators. “Most Accurate” (MA) ABI measurements used the higher of the two ankle readings and the higher of the two brachial readings to calculate the result. “Least Accurate” (LA) measurements used the lower of the two ankle readings and the higher of the two brachial readings. Results: 118 study subjects were enrolled: mean age 32.8 years (range 19 to 49), 50% female, none with known peripheral vascular disease or extremity trauma, and none with documented femoral artery bruit at the time of the study. When a single provider performed LA ABI’s, the false positive rate was 29%, while single provider MA ABI’s lowered the false positive rate to 2%. For two provider ABI’s, these rates were 4% and 0%, respectively. Conclusions: We identified an unacceptably high rate of false positive ABI results if the test is performed incorrectly. We recommend strict adherence to standardized ABI measurement protocols to minimize this error. Ideally, an ABI measurement of less than 0.9 in a patient with lower extremity trauma should be confirmed by a second provider in order to minimize the risk of inappropriately implementing invasive diagnostic procedures.

Kikuchi’s disease or histiocytic necrotizing lymphadenitis is a very rare benign disease which is most common in Asia. This disease has a special predilection for cervical lymph nodes of young females. Clinical features of Kikuchi’s disease may resemble commonly with tuberculosis and lymphoma. Excision biopsy of lymph node can confirm the diagnosis as it has some typical characteristics. We report a case of young female student who presented with fever and cervical lymphadenopathy. Kikuchi’s disease was diagnosed after biopsy from cervical lymph node. She was given symptomatic treatment and her recovery was uneventful.

The Women’s Health Initiative [WHI] study ended in 2002 because of the adverse effects of Premarin and Provera, including cardiovascular events [heart attack, stroke and pulmonary embolism] which affected 7% of the participants, and almost doubling the risk of breast cancer and mammographic abnormalities. It led to a major reduction in the use of hormone therapy for menopausal women, with significant consequences in terms of quality of life and possibly overall health. The following is a report of 460 menopausal women, who were administered multiple hormones, according to a rationalized approach described below. All patients received bio-identical estrogen and progesterone; 227 and 349 received testosterone and DHEA, respectively for suboptimal levels; 103 received thyroid replacement, and 89 received a growth hormone secretagogue for suboptimal Insulin like Growth factor [IGF]. No patient developed any cardiovascular complications over an average duration of four years. Premarin and Provera would have resulted in 33 such events. There were no hormone related breast cancers and no increase in mammographic abnormalities. In fact, eight abnormal [dense/cystic] mammograms showed improvement on follow up. There is a need to look into fresh approaches that could improve the quality and possibly quantity of menopausal years.

Cardiac wound bed drainage is achieved via large-bore plastic tube(s), which are typically removed within 48 hours, to lower risk of arrhythmia and tissue damage. While standard tube removal is simple and rapid, tubes inadvertently sutured to the chest wall are removed through a complex surgical procedure. Herein, we describe a novel tube extraction procedure, using an endoscopic scissor under bronchoscopic guidance. Tube extraction was achieved in all three presented cases, and patient recovery and wound healing periods were similar to those standard removal of nonsutured tubes. This report demonstrates the safety and convenience of the proposed method as a feasible alternative to invasive chest tube extraction.

Background: Many children are experiencing their parents’ separation and General practitioners (GPs) often have the responsibility to medically follow these young patients. Objectives: The goals were to identify the main difficulties GPs are confronted with when following children of separated (or divorced) parents and to find ways to improve the quality of these children’s continuous medical monitoring. Methods: Eight focus groups of GPs were organized in 2004 in the French-speaking Community of Belgium. Each meeting focused on couples separated for less than three years, with children aged 0 to 15. The debates were analysed with the QSR N5 software. Data saturation was obtained after four focus groups. Results: The viewpoint of GPs is: 1. Divorce affects the working conditions of GPs. 2. Conflicts between the parents cause difficulties for the GP, particularly the fact of being « exploited » by the parents. 3. All GPs do not have the same attitude towards conflicts between the parents; only some of them will try to « manage » the conflicts to improve the child’s situation. 4. Especially in the case of conflicts, parental separation brings a risk for the child: psychological disorders, physical health problems. 5. The professional attitudes of GPs can have a positive influence on the child’s development, including direct child-centred communication with the child. 6. Some actions, such as producing sickness certificates or official reports of neglect, can aggravate these children’s situation, especially in the case of conflicts between the parents. Discussion: Parental separation could be an independent risk factor for the child’s health by inducing some difficulties of tracking in primary care medicine. If this is confirmed, in case of a family breakdown, the GP should adapt the practice of prevention and care, recognizing young patients as most at risk. In order to confirm the possible impact of family status, cohort studies must be conducted either transverse observational targeting unselected paediatric populations of different ages, or even better in prospective research. Given the high prevalence of parental separation in Belgium, the influence of these situations should be measured in terms of public health.