Female genital mutilation and its prevention: a challenge for paediatricians.

Female genital mutilation (FGM) is defined as an injury of the external female genitalia for cultural or non-therapeutic reasons. FGM is mainly performed in sub-Saharan and Eastern Africa. The western health care systems are confronted with migrants from this cultural background. The aim is to offer information on how to approach this subject. The degree of FGM can vary from excision of the prepuce and clitoris to infibulation. Infections, urinary retention, pain, lesions of neighbouring organs, bleeding, psychological trauma and even death are possible acute complications. The different long-term complications include the risk of reduced fertility and difficulties during labour, which are key arguments against FGM in the migrant community. Paediatricians often have questions on how to approach the subject. With an open, neutral approach and basic knowledge, discussions with parents are constructive. Talking about the newborn, delivery or traditions may be a good starting point. Once they feel accepted, they speak surprisingly openly. FGM is performed out of love for their daughters. We have to be aware of their arguments and fears, but we should also stress the parents' responsibility in taking a health risk for their daughters. It is important to know the family's opinion on FGM. Some may need support, especially against community pressure. As FGM is often performed on newborns or at 4-9 years of age, paediatricians should have an active role in the prevention of FGM, especially as they have repeated close contact with those concerned and medical consequences are the main arguments against FGM.

Personality, psychosocial and health-related predictors of quality of life in old age.

OBJECTIVES: Beyond its well-documented association with depressive symptoms across the lifespan, at an individual level, quality of life may be determined by multiple factors: psychosocial characteristics, current physical health and long-term personality traits. METHOD: Quality of life was assessed in two distinct community-based age groups (89 young adults aged 36.2 ± 6.3 and 92 older adults aged 70.4 ± 5.5 years), each group equally including adults with and without acute depressive symptoms. Regression models were applied to explore the association between quality of life assessed with the World Health Organization Quality of Life - Bref (WHOQOL-Bref) and depression severity, education, social support, physical illness, as well as personality dimensions as defined by the Five-Factor Model. RESULTS: In young age, higher quality of life was uniquely associated with lower severity of depressive symptoms. In contrast, in old age, higher quality of life was related to both lower levels of depressive mood and of physical illness. In this age group, a positive association was also found between quality of life and higher levels of Openness to experience and Agreeableness personality dimensions. CONCLUSION: Our data indicated that, in contrast to young cohorts, where acute depression is the main determinant of poor quality of life, physical illness and personality dimensions represent additional independent predictors of this variable in old age. This observation points to the need for concomitant consideration of physical and psychological determinants of quality of life in old age.

Rehabilitation needs assessment in persons with spinal cord injury following the 2010 earthquake in Haiti: a pilot study using an ICF-based tool.

OBJECTIVE: The aim of this pilot study was to describe problems in functioning and associated rehabilitation needs in persons with spinal cord injury after the 2010 earthquake in Haiti by applying a newly developed tool based on the International Classification of Functioning, Disability and Health (ICF). DESIGN: Pilot study. SUBJECTS: Eighteen persons with spinal cord injury (11 women, 7 men) participated in the needs assessment. Eleven patients had complete lesions (American Spinal Injury Association Impairment Scale; AIS A), one patient had tetraplegia. METHODS: Data collection included information from the International Spinal Cord Injury Core Data Set and a newly developed needs assessment tool based on ICF Core Sets. This tool assesses the level of functioning, the corresponding rehabilitation need, and required health professional. Data were summarized using descriptive statistics. RESULTS: In body functions and body structures, patients showed typical problems following spinal cord injury. Nearly all patients showed limitations and restrictions in their activities and participation related to mobility, self-care and aspects of social integration. Several environmental factors presented barriers to these limitations and restrictions. However, the availability of products and social support were identified as facilitators. Rehabilitation needs were identified in nearly all aspects of functioning. To address these needs, a multidisciplinary approach would be needed. CONCLUSION: This ICF-based needs assessment provided useful information for rehabilitation planning in the context of natural disaster. Future studies are required to test and, if necessary, adapt the assessment.

A dynamic assessment of medication-taking behavior during pregnancy and postpartum: should cART adherence be reinforced during postpartum?

This study compared adherence (persistence and execution) during pregnancy and postpartum in HIV-positive women having taken part in the adherence-enhancing program of the Community Pharmacy of the Department of Ambulatory Care and Community Medicine in Lausanne between 2004 and 2012. This interdisciplinary program combined electronic drug monitoring and semi-structured, repeated motivational interviews. This was a retrospective, observational study. Observation period spread over from first adherence visit after last menstruation until 6 months after childbirth. Medication-taking was recorded by electronic drug monitoring. Socio-demographic and delivery data were collected from Swiss HIV Cohort database. Adherence data, barriers and facilitators were collected from pharmacy database. Electronic data were reconciled with pill-count and interview notes in order to include reported pocket-doses. Execution was analyzed over 3-day periods by a mixed effect logistic model, separating time before and after childbirth. This model allowed us to estimate different time slopes for both periods and to show a sudden fall associated with childbirth. Twenty-five pregnant women were included. Median age was 29 (IQR: 26.5, 32.0), women were in majority black (n_17,68%) and took a cART combining protease and nucleoside reverse transcriptase inhibitors (n_24,96%). Eleven women (44%) were ART-naı¨ve at the beginning of pregnancy. Twenty women (80%) were included in the program because of pregnancy. Women were included at all stages of pregnancy. Six women (24%) stopped the program during pregnancy, 3 (12%) at delivery, 4 (16%) during postpartum and 12 (48%) stayed in program at the end of observation time. Median number of visits was 4 (3.0, 6.3) during pregnancy and 3 (0.8, 6.0) during postpartum. Execution was continuously high during pregnancy, low at beginning of postpartum and increased gradually during the 6 months of postpartum. Major barriers to adherence were medication adverse events and difficulties in daily routine. Facilitators were motivation for promoting child-health and social support. The dramatic drop and very slow increase in cART adherence during postpartum might result in viral rebound and drug resistance. Although much attention is devoted to pregnant women, interdisciplinary care should also be provided to women in the community during first trimester of postpartum to support them in sustaining cART adherence.

Predictors of HIV-protection behaviour in HIV-positive men who have sex with casual male partners: a test of the explanatory power of an extended Information-Motivation-Behavioural Skills model.

This prospective study applies an extended Information-Motivation-Behavioural Skills (IMB) model to establish predictors of HIV-protection behaviour among HIV-positive men who have sex with men (MSM) during sex with casual partners. Data have been collected from anonymous, self-administered questionnaires and analysed by using descriptive and backward elimination regression analyses. In a sample of 165 HIV-positive MSM, 82 participants between the ages of 23 and 78 (M=46.4, SD=9.0) had sex with casual partners during the three-month period under investigation. About 62% (n=51) have always used a condom when having sex with casual partners. From the original IMB model, only subjective norm predicted condom use. More important predictors that increased condom use were low consumption of psychotropics, high satisfaction with sexuality, numerous changes in sexual behaviour after diagnosis, low social support from friends, alcohol use before sex and habitualised condom use with casual partner(s). The explanatory power of the calculated regression model was 49% (p<0.001). The study reveals the importance of personal and social resources and of routines for condom use, and provides information for the research-based conceptualisation of prevention offers addressing especially people living with HIV ("positive prevention").

Morbilidad psíquica, existencia de diagnóstico y consumo de psicofármacos. Diferencias por comunidades autónomas según la Encuesta Nacional de Salud de 2006

Background: Most of the studies on sychological distress in Spain have been conducted in small geographical areas or specific population groups. However, there are no studies that provide representative data for each Autonomous Community (AC). The objectives of this paper are to determine, both in Spain and in the AC, the prevalence of psychological distress, diagnosis, use of psychoactive medication, social support and self-perceived health, as well as to study the association between psychological distress and the rest of the variables. Methods: Cross-sectional study, using data from the 2006 National Health Survey, that was completed by 29,478 persons. Variables studied: sociodemographics, psychological distress (GHQ-12), self-perceived health, mental disorder diagnosis, functional social support (Duke) and use and prescription of psychoactive medication. Results: The prevalence of psychological distress in Spain was 20,1%; the highest prevalence was found in Canary Islands (28,2%) and the lowest in La Rioja (12,2%). Among those who presented psychological distress, 62,4% had never received a mental disorder diagnosis, and 71,6% had not used psychoactive medication in the last year. The highest prevalences of non-diagnosed cases (81,8%) and cases non-treated with psychoactive medication (83,1%) were found in La Rioja, whereas the lowest prevalences were found in Asturias. Eight percent of the persons who presented psychological distress had low social support and 63,8% reported bad self-perceived health. Conclusions: Psychological distress is a prevalent phenomenon, and more than half of the persons who suffer it receive neither a diagnosis nor psychoactive medication. Moreover, there are considerable differences between the AC.

Telemedicine influence on the follow-up of type 2 diabetes patients.

OBJECTIVE This study was designed to evaluate the impact of a teleassistance system on the metabolic control of type 2 diabetes patients. RESEARCH DESIGN AND METHODS We conducted a 1-year controlled parallel-group trial comparing patients randomized (1) to an intervention group, assigned to a teleassistance system using real-time transmission of blood glucose results, with immediate reply when necessary, and telephone consultations, or (2) to a control group, being regularly followed-up at their healthcare center. Study subjects were type 2 diabetes patients >30 years of age followed in the primary care setting. RESULTS A total of 328 type 2 diabetes patients were recruited from 35 family practices in the province of Málaga, Spain. There was a reduction in hemoglobin A1c after 12 months from 7.62 +/- 1.60% to 7.40 +/- 1.43% (P = 0.027) in the intervention group and from 7.44 +/- 1.31% to 7.35 +/- 1.38% (P = 0.303) in the control group. The difference in the change between groups was not statistically significant. There was also a significant decrease in systolic and diastolic blood pressure, total cholesterol, low-density lipoprotein cholesterol, and body mass index in the intervention group. In the control group, the only significant decline was in low-density lipoprotein cholesterol. CONCLUSIONS A teleassistance system using real-time transmission of blood glucose results with an option to make telephone consultations is feasible in the primary care setting as a support tool for family physicians in their follow-up of type 2 diabetes patients.

Adolescent survivors of childhood cancer: are they vulnerable for psychological distress?

OBJECTIVES: We aimed to (i) evaluate psychological distress in adolescent survivors of childhood cancer and compare them to siblings and a norm population; (ii) compare the severity of distress of distressed survivors and siblings with that of psychotherapy patients; and (iii) determine risk factors for psychological distress in survivors. METHODS: We sent a questionnaire to all childhood cancer survivors aged <16 years when diagnosed, who had survived &#8805; 5 years and were aged 16-19 years at the time of study. Our control groups were same-aged siblings, a norm population, and psychotherapy patients. Psychological distress was measured with the Brief Symptom Inventory-18 (BSI-18) assessing somatization, depression, anxiety, and a global severity index (GSI). Participants with a T-score &#8805; 57 were defined as distressed. We used logistic regression to determine risk factors. RESULTS: We evaluated the BSI-18 in 407 survivors and 102 siblings. Fifty-two survivors (13%) and 11 siblings (11%) had scores above the distress threshold (T &#8805; 57). Distressed survivors scored significantly higher in somatization (p=0.027) and GSI (p=0.016) than distressed siblings, and also scored higher in somatization (p &#8804; 0.001) and anxiety (p=0.002) than psychotherapy patients. In the multivariable regression, psychological distress was associated with female sex, self-reported late effects, and low perceived parental support. CONCLUSIONS: The majority of survivors did not report psychological distress. However, the severity of distress of distressed survivors exceeded that of distressed siblings and psychotherapy patients. Systematic psychological follow-up can help to identify survivors at risk and support them during the challenging period of adolescence.

La violencia contra la mujer en la pareja como factor asociado a una mala salud física y psíquica.

OBJECTIVE: To study the impact of intimate partner violence (IPV) on women's physical and psychological health. DESIGN: Cross-sectional study. SETTING:Primary care centers in 3 Andalusian provinces. PATIENTS: A total of 425 women, aged 18 to 65 years, were recruited following the same randomisation process in 6 primary care centers. MEASUREMENTS: A self-administered structured questionnaire for this study was used to gather the information. As well as sociodemographic variables, the instrument included questions about IPV, physical health indicators (chronic disease and type, lifetime surgeries, days in bed), psychological health (psychological morbidity, use of tranquilizers, antidepressants, pain killers, alcohol and recreational drugs), self-perceived health and social support. RESULTS: Of 425 women, 31.5% ever experienced any type of partner violence. Women experiencing IPV were more likely to suffer a chronic disease. IPV was significantly associated with a number of adverse health outcomes, including spending more than 7 days in bed in the last three months (ORa=2.96; CI 95%, 1.00-8.76), psychological morbidity (ORa=2.68; CI 95%, 1.60-4.49) and worse self-perceived health (ORa=1.89; CI 95%, 1.04-3.43), after controlling for potential confounding variables. CONCLUSION: This study shows that ever experiencing IPV is associated with a worse psychological and self-perceived health. Physical injuries are not the only "evidence" of the presence of IPV. Primary health care professionals are in a privileged position to help women who are abused by their partners.

The Impact of Personality and Culture on the Job Demands-Control Model of Job Stress

Among the various work stress models, one of the most popular has been the job demands-control (JDC) model developed by Karasek (1979), which postulates that work-related strain is highest under work conditions characterized by high demands and low autonomy. The absence of social support at work further increases negative outcomes. This model, however, does not apply equally to all individuals and to all cultures. This review demonstrates how various individual characteristics, especially some personality dimensions, influence the JDC model and could thus be considered buffering or moderator factors. Moreover, we review how the cultural context impacts this model as suggested by results obtained in European, American, and Asian contexts. Yet there are almost no data from Africa or South America. More crosscultural studies including populations from these continents would be valuable for a better understanding of the impact of the cultural context on the JDC model.

The effect of recalled previous work environment on return to work after a rehabilitation program including vocational aspects for trauma patients.

INTRODUCTION: The aim of the present study was to assess the association between remembered previous work place environment and return to work (RTW) after hospitalisation in a rehabilitation hospital. METHODS: A cohort of 291 orthopedic trauma patients discharged from hospital between 15 December 2004 and 31 December 2005 was included in a study addressing quality of life and work-related questions. Remembered previous work environment was measured by Karasek's 31-item Job Content Questionnaire (JCQ), given to the patients during hospitalisation. Post-hospitalisation work status was assessed 3 months, 1, and 2 years after discharge, using a questionnaire sent to the ex-patients. Logistic regression models were used to test the role of four JCQ variables on RTW at each time point while controlling for relevant confounders. RESULTS: Subjects perceiving a higher physical demand were less likely to return to work 1 year after hospital discharge. Social support at work was positively associated with RTW at all time points. A high job strain appeared to be positively associated with RTW 1 year after rehabilitation, with limitations due to large confidence intervals. CONCLUSIONS: Perceptions of previous work environment may influence the probability of RTW. In a rehabilitation setting, efforts should be made to assess those perceptions and, if needed, interventions to modify them should be applied.

Networks of PhD Students and Academic Performance: A Comparison across Countries

In this article we compare regression models obtained to predict PhD students’ academic performance in the universities of Girona (Spain) and Slovenia. Explanatory variables are characteristics of PhD student’s research group understood as an egocentered social network, background and attitudinal characteristics of the PhD students and some characteristics of the supervisors. Academic performance was measured by the weighted number of publications. Two web questionnaires were designed, one for PhD students and one for their supervisors and other research group members. Most of the variables were easily comparable across universities due to the careful translation procedure and pre-tests. When direct comparison was notpossible we created comparable indicators. We used a regression model in which the country was introduced as a dummy coded variable including all possible interaction effects. The optimal transformations of the main and interaction variables are discussed. Some differences between Slovenian and Girona universities emerge. Some variables like supervisor’s performance and motivation for autonomy prior to starting the PhD have the same positive effect on the PhD student’s performance in both countries. On the other hand, variables like too close supervision by the supervisor and having children have a negative influence in both countries. However, we find differences between countries when we observe the motivation for research prior to starting the PhD which increases performance in Slovenia but not in Girona. As regards network variables, frequency of supervisor advice increases performance in Slovenia and decreases it in Girona. The negative effect in Girona could be explained by the fact that additional contacts of the PhD student with his/her supervisor might indicate a higher workload in addition to or instead of a better advice about the dissertation. The number of external student’s advice relationships and social support mean contact intensity are not significant in Girona, but they have a negative effect in Slovenia. We might explain the negative effect of external advice relationships in Slovenia by saying that a lot of external advice may actually result from a lack of the more relevant internal advice

Désir de mort, désir de vie et fin de vie [Desire to die, desire to live at the end of life]

Since a couple of years, physicians are confronted with an increasing request of end of life patients asking for a dying facilitated process. The reasons for this are multiple and complex. Existential suffering, increased by depression, a feeling of loss of meaning or dignity and/or being a burden, seems to be a significant factor. Social isolation and physical symptoms seem to be only contributory. The identification of "protecting elements" such as spiritual well-being or a preserved sense of dignity offers new opportunities for care. Providing a space for dialogue by exploring the patient's expectations and fears, his knowledge of care options available at the end of life, his own resources and difficulties frequently contribute to decrease suffering.

Do youths gamble? You bet! A Swiss population-based study.

OBJECTIVES: To establish the gambling prevalence among Swiss resident youths, to estimate the associations between gambling frequency and substance use, poor mental health and social support and to determine the correlation between gambling pattern and gambling frequency. METHODS: Cross-sectional population-based survey conducted in 2007. From 1233 eligible participants aged 15-24 years, adequate information was available for 1116 (582 males), distributed into: non- (n=577), occasional (n=388) and frequent gamblers (n=151). Outcome measures: Substance use, social activities, presence of a reliable person among friends or family, psychological distress, major depression and gambling pattern. RESULTS: Overall, the 48.3% (n=539) of youths who had gambled during the previous year; were older and more likely to be male than non-gamblers. 13.5% (n=151) gambled at least weekly and could be differentiated from occasional gamblers on the basis of their gambling pattern. After controlling for gender, age and language area, occasional gamblers were significantly more likely to be occasional binge drinkers, whereas frequent gamblers were more likely to be daily smokers. CONCLUSION: Almost half of Swiss resident youths are involved in gambling. Both occasional and frequent gambling are associated with further health compromising behaviour. Practitioners dealing with young people should be aware that gambling is a behaviour that might be part of a more global risky behaviour framework.

Les enjeux de l'allaitement maternel pour les nouveau-nés hospitalisés [Issues surrounding the breastfeeding of hospitalized newborns].

The nutritional and physiological qualities of breast milk make it the best food for newborns, favouring their wellbeing and growth. The implementation of a programme encouraging the breastfeeding of hospitalised newborns in care departments requires specific methods of organisation, as well as constant and adapted support from health professionals.