Journal of General Practice

There is a lack of knowledge about the diagnostic process in medical experts, and there is no clear consensus regarding its systematization in practice, teaching and evaluation. For the medical expert, clinical reasoning has become an ingrained form of thinking and is done "without realizing". The diagnostic process is a mental operation through which pathology is identified and the disease is evaluated. But the diagnosis is made by medical expert in a similar way as of the painter when he manages to highlight a figure on a background, when recognizing the edges by contrast, and so, only by observing colour in its context can you begin to understand its nature. For the family doctor, the same problem takes different forms according to its background. There are different diagnoses of the same symptom according to contexts. The professional intuition is sometimes marvellous and sometimes flawed. To map the boundary conditions that separate true intuitive skill from overconfident and biased impressions it should be based in the contextual evidence. The way to arrive at objective decisions is to contextualize. The complexity of family medicine lies in the contextualization of medical care in each patient.

Objective: To describe differences in verbal behaviour style in interviews of patients females with patient's companion (triadic consultations) and patient’s females without patient's companion (dyadic consultations) in family medicine.

Participants and Methods: Secondary analysis of existing dataset coded to explore patient-clinician verbal communication during ambulatory visits in a family medicine office in a health Centre in Toledo (Spain) was carried out. A qualitative study was performed by audio recording of the consultations and verbal content analysis of the interviews, based on the identification of 6 categories of classification of behaviours of the interaction process (Proposing, Supporting/Agreeing, Disagreeing, Giving Information, Seeking Information, and Building). A convenience sample was carried out. A suitable sample number was considered when saturation occurred. Quantitative methodology was used as a technique to control the reliability and biases.

Results: 5 unaccompanied consultations and 7 consultations with companion were included in the analysis. The female patients with a companion show 2/3 more verbal behaviours (165 vs. 101) with slightly more behaviours of “Supporting or Agreeing” (42% vs. 34%), but less of “Giving Information” (43% vs. 53%) than when the female patients go unaccompanied, predominating these two types of behaviours in both modalities. Consultation with female patients with a companion shows almost twice as many verbal behaviours of the doctor vs. the consultation with unaccompanied women (186 vs. 100), and is longer (6.4 ' vs. 7.7').

Conclusions: This study shows that consultations of female patients with a companion are longer and more verbal behaviours are performed. In patients female the triadic consultations have more agreements, but less information is obtained than in the dyadic, and in general there is mixed results. Female patients show a clear predominance of verbal behaviours of “Giving information” and “Supporting or Agreeing”, both with or without companion in the consultation.

Introduction: The laparoscopic reversal Hartmann procedure is a challenging technique showing promising results in comparison to the open procedure.

Aim: Report a single surgeon experience showing promising results.

Results: It’s a twelve patient’s case series. The median age was 62 years old. The mean operative time was 148.16 min (75-210 min). No per-operative complication was reported. Only one procedure was converted to laparotomy due to severe pelvic adhesions. All patients ambulated on postoperative day 1. The Mean time to the recovery of the bowel movement was Two days (1 to 4 days). The mean time to Oral analgesia intake was 1.66 days (1 to 3). The mean time of hospital stay was 5.66 Days (4 to 8). Two patients had complication in a mean time of 18 days after the surgery.

Conclusion: The laparoscopic reversal Hartmann procedure is a safe technique showing promising results but in the hand of trained laparoscopic surgeon.

Background: The current treatment of locally advanced lower and middle rectum’s adenocarcinoma is well codified. It is based on neoadjuvant radiotherapy (NRT) followed by surgical excision. However, two broad radiotherapy approaches are being debated: short course of hypo-fractionated radiation therapy “SRT” (5 GY × 5 days) and long course concomitant radio-chemotherapy “CRT” using higher radiation dose (45-50 GY over 5 weeks) combined with chemotherapy. The first approach allows taking care of about 4 times more patients compared to the second in a same period. SRT was introduced at a large scale at the Pierre ET Marie Curie center (Algiers) in May 2010 by a new multidisciplinary board (Rectum board), aiming to reduce long-lasting schedules. Purpose: The aim of the current study is to evaluate the SCR introduction effect on the access rate to NRT and also to define its impact on treatment efficacy by assessing the primary tumor response (downsizing and downstaging) and the complete resection margin R0 rates. Patients and methods: In this study, the feasibility of short-course radiotherapy was evaluated. A specimen from 297 patients was studied over 10 years. We took May 2010 as a reference point to divide this specimen into two groups, group 1 in care before May 2010 (n=130) and group 2 treated after May 2010 (n=167). Three therapeutics protocols were used: long-course chemoradiation, short-course radiotherapy and long-course radiotherapy. Results: In the group 1, only 33% (43/130) of patients received NRT (SRT=2.5%, CRT=60.5%, LCR=37%). In the second group (after May 2010), 65% (113/167) of patients were able to access an NRT (SRT=73%, CRT=21%, LCR=6%) (p<0.001). Complete response (ypT0N0) was obtained in 13 patients (30%) of Group 1 and 2 patients (2%) of group 2 (p<0.001). Conclusions: The large scaled introduction of short course radiotherapy and the creation of the rectum board have allowed doubling the number of patients which benefited from neoadjuvant radiotherapy. Although, the complete responses rate had significantly dropped.

Amyotrophic lateral sclerosis (ALS, also called Charcot disease, Lou Gehrig disease), is a progressive, neurodegenerative disease caused by the degeneration of motor neurons in the brain and spinal cord. There is no cure. This report describes a case of motor neuron disease with typical weakness in one leg, one hand and the tongue. Despite of treatment with riluzole, symptoms progressed relatively fast. Therefore, the patient decided to take cannabidiol (CBD, 2 × 200 mg/day) as co-medication, which was started 8 weeks after riluzole, and increased to a daily dose of 2 × 300 mg. Within 6 weeks, the impaired function of the right hand and foot reversed almost completely and dysphagia partially. Improvement was maintained for about 10 weeks, when again a slow progression of dysarthria and dysphagia was observed. Eighteen months after onset, speech is almost completely lost, and dysphagia also progressed. However, symptoms of the limbs (weakness, fasciculation, atrophy) worsened much less. It is concluded, that Co-medication with CBD may be able to slow down the progression of some but not all symptoms of motor neuron disease.

The possible teratogenic effects of maternal antiepileptic drugs (AEDs) on the development of the fetus are of major concern. The fetal risks imposed by these drugs must be weighed against the risks associated with untreated maternal epilepsy not being treated. Here, we describe an infant with a neural tube defect caused by AEDs prescribed to the mother during her pregnancy. A female infant was delivered by means of cesarean section after 37+6 weeks of gestation. Her 21-year-old mother had been diagnosed with epilepsy at 2 years of age, following brain surgery performed for a traffic accident injury. Since the age of 6 years, the mother had been medicated with lamotrigine (Lamictal®), levetiracetam (Keppra®), and valproate (Depakote®). At birth, the baby exhibited pallor, severe macrocephaly, a large anterior fontanelle (4 cm × 4 cm), and sutural widening. On her lower back, there was a 3 cm open spinal dysraphism exposing nervous tissue. On the 11th postnatal day, a ventriculo-peritoneal shunt was placed and a myelomeningocele removal operation was performed. After this operation, the head circumference decreased from 44.0 cm to 35.8 cm, and the post-operative period was uneventful. The patient was discharged on the 24th day. Several case reports and studies have reported that valproate or multi-antiepileptic medication that contains valproate increased the risk of neural tube defects in the offspring. For women of childbearing age who use AEDs, clinicians should review pregnancy risk regularly and consider adjusting medication whenever possible. Additionally, while examing newborns with neural tube defects, clinicians should review prenatal maternal medication history thoroughly.

Background: The early and accurate diagnosis of acute myocardial infarction may be a challenging task for doctors in the emergency room. The patient’s history, electrocardiographic and cardiac markers data are sometimes non diagnostic and misleading which may lead to death. In this case, physician’s responsibility may be engaged. Case report: A 48-year-old man was admitted in the Emergency Department because of chest pain. Exploration (Percritical ECG, enzymatic levels and transthoracic echocardiogram) did not show any abnormality. He received a symptomatic treatment and was allowed to return home. The patient was confined to bed during his stay at home because of persisting chest pain. Two days later, he presented syncope and arrived dead to hospital. At autopsy, an abundant hemopericardium made by coagulated blood was noted, associated with an obstruction of the circumflex of about 90% of its light. A rupture of the myocardium was repaired in the lateral wall of left ventricle, surrounded by a semi recent infarction. Discussion: The peculiarity of this case is the difficulty of the diagnosis of the myocardial infarction because of the normality of the enzymatic assessment and the absence of electric modifications during the crisis and two hours later. Misdiagnosed cases can lead health professionals to legal suits. The claims about diagnostic error can be usually subject to trials in both of penal judgment and compensation trial.

Even though there are well over 20,000 studies of Attention-Deficit/Hyperactivity Disorder (ADHD), it is still viewed with skepticism by some and often remains stigmatized by the media. Hence, given the continuing challenges to the validity of ADHD, this article provided a concise overview of the evidence that establishes ADHD as brain disorder associated with a set of well-defined symptoms that causes serious impairment in many life activities.

Background: Idiopathic Hypertrophic Pyloric Stenosis (IHPS) is one of the most common surgical conditions of early infancy, presenting in 1.5 to 4 per 1000 live births. Despite this high prevalence, the precise etiology remains poorly understood. The diagnosis is made primarily with history and physical examination. Projectile, non-bilious vomiting is the classic presentation of an infant with IHPS. The typical physical exam findings include visible peristaltic waves and palpation of the olive mass in the upper abdomen. In the absence of a palpable mass, an upper gastrointestinal (UGI) barium study or ultrasonographic evaluation will usually make the diagnosis. Ultrasound is the preferred modality to diagnose IHPS. Demonstration of pyloric muscle thickness of 3.5 mm to 4 mm or more and pyloric channel length of 16 mm or more increases the specificity of the ultrasound to 100%.

Objectives: This prospective study aims to evaluate the ultrasonographic accuracy in the diagnosis and exclusion of Idiopathic Hypertrophic Pyloric Stenosis in infants presenting with non-bilious vomiting and no palpable pyloric mass, suspected to have IHPS.

Patients and Methods: Prospective study carried out between June 2006 and June 2016 at Babylon Maternity and Pediatric Teaching Hospital. One hundred forty-six (146) infants suspected of having IHPS presenting with nonbilious vomiting and no palpable pyloric (olive) mass were enrolled in this study. All infants sent for abdominal ultrasound examination. The sonographic findings categorized as positive and negative IHPS. Surgery done for patients as indicated according to diagnostic positive criteria and the operative findings compared to ultrasound findings.

Results: Sixty-nine (69) infants with positive ultrasound criteria underwent surgery and the diagnosis was confirmed intra-operatively for (67) patients, while negative for (2) infants. In (77) infants with negative ultrasound criteria, the diagnosis of IHPS excluded for (75) patients, and all observed and treated conservatively as pylorospasm or chalasia (Gastro-esophageal reflux), only 2 patients then need pyloromyotomy. About 88% of patients with positive ultrasound criteria (69) diagnosed from third to sixth week of age and about 12% of patients in this study were diagnosed later. Sensitivity and the Specificity of ultrasound to confirm the diagnosis of (IHPS) in this study were 97.1% and 97.4% respectively.

Conclusion: Ultrasonography is the investigation of choice for early diagnosis of IHPS before significant fluid and electrolyte imbalance occur. It is cost effective, rapid, harmless, non-invasive procedure mostly available and easy to perform. It’s the method of choice for both diagnosis and exclusion of pyloric stenosis. Indication for surgical interference could safely be based on positive ultrasound result.

Relaxation therapy is one of the widely used therapies conducted in clinical psychology practice. The purpose of relaxation is to reduce tension in the various muscles in the body system. Relaxation therapy is considered a noninvasive intervention and is effective in treating a number of stress-related conditions. Both young people and adults benefit from relaxation therapies. Though this intervention is non-invasive, there is a need for proper screening of patients especially elderly clients and people with special conditions before relaxation therapies are conducted. Failure to screen individuals may result in some complications for the client in treatment. A clinical tool has therefore been developed to guide and help practitioners adequately screen their clients for relaxation therapy. At the end of the tool is an agreement section to be signed by the client and therapist before the relaxation therapy procedure.