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Inequalities in the utilisation of primary and specialist physicians in Europe - a systematic review
(2019)
Background: The evidence on inequalities in health clearly shows that people with lower socioeconomic status (SES) have poorer health and higher mortality. Nevertheless, generalized evidence for inequalities in healthcare is lacking. So far, the international literature was only summarised with regard to inequalities in the utilisation of disease-specific treatment. Therefore, our aim was to synthetize the literature on socioeconomic inequalities in the utilisation of primary and specialist physicians in the general population.
Methods: This systematic review searched Medline und Web of Science from 2004 to 2018. Articles that reported quantitative data on the association of SES with utilisation of primary or specialist physicians in Europe were included. Title and abstract screening were performed by two independent researchers and 50 full texts are currently sifted whether they fulfil the inclusion criteria.
Results: The studies analysed utilisation of physicians in terms of probability or frequency. The initial check of the studies indicates that socioeconomic inequalities in the utilisation of physicians differ between primary and specialist care. Specialist physicians were found to be visited with a higher probability and more often by the least disadvantaged in most studies. Inequalities in the utilisation of primary physicians revealed to be more diverse with a weak pattern of equally distributed probability of GP visits and more frequent utilisation by the disadvantaged.
Conclusions: The preliminary results indicate that pro-rich utilisation seems to be more pronounced in visiting specialists compared to primary health care. Aiming to reduce inequalities in healthcare, public health actions might primarily focus on reaching a needs-based consultation of specialist physicians.
Intestinal colonization is influenced by the ability of the bacterium to inhabit a niche, which is based on the expression of colonization factors. Escherichia coli carries a broad range of virulence-associated genes (VAGs) which contribute to intestinal (inVAGs) and extraintestinal (exVAGs) infection. Moreover, initial evidence indicates that inVAGs and exVAGs support intestinal colonization. We developed new screening tools to genotypically and phenotypically characterize E. coli isolates originating in humans, domestic pigs, and 17 wild mammal and avian species. We analyzed 317 isolates for the occurrence of 44 VAGs using a novel multiplex PCR microbead assay (MPMA) and for adhesion to four epithelial cell lines using a new adhesion assay. We correlated data for the definition of new adhesion genes. inVAGs were identified only sporadically, particularly in roe deer (Capreolus capreolus) and the European hedgehog ( Erinaceus europaeus). The prevalence of exVAGs depended on isolation from a specific host. Human uropathogenic E. coli isolates carried exVAGs with the highest prevalence, followed by badger (Meles meles) and roe deer isolates. Adhesion was found to be very diverse. Adhesion was specific to cells, host, and tissue, though it was also unspecific. Occurrence of the following VAGs was associated with a higher rate of adhesion to one or more cell lines: afa-dra, daaD, tsh, vat, ibeA, fyuA, mat, sfa-foc, malX, pic, irp2, and papC. In summary, we established new screening methods which enabled us to characterize large numbers of E. coli isolates. We defined reservoirs for potential pathogenic E. coli. We also identified a very broad range of colonization strategies and defined potential new adhesion genes.
Abstract
BACKGROUND:
Different strategies of colonization or infection by E. coli result in formation of certain adhesion patterns which help also in classifying intestinal E. coli into pathotypes. Little is known about adhesion patterns and host- and tissue adaption of commensal E. coli and about E. coli originating in clinically healthy hosts carrying pathotype-specific virulence-associated genes.
FINDINGS:
Adhesion pattern of E. coli (n = 282) from humans and from 18 animal species were verified on intestinal human Caco-2 and porcine IPEC-J2 cells and, furthermore, for comparison on human urinary bladder 5637, porcine kidney PK-15 epithelial and HEp-2 cells. The analysis was carried out on 150,000 images of adhesion assays.Adhesion patterns were very diverse; 88 isolates were completely non-adherent, whereas 194 adhered to at least one cell line with the dominant adhesion patterns "diffusely distributed" and "microcolony formation". Adhesion patterns "chains" and "clumps" were also visible. Chain formation was mediated by the presence of epithelial cells. Clump formation was very specific on only the 5637 cell line. All enteropathogenic (eae+) E. coli (EPEC; n = 14) were able to form microcolonies which was cell line specific for each isolate. Most EPEC formed microcolonies on intestinal IPEC-J2 and Caco-2 but several also on urinary tract cells. Shigatoxin-producing (stx+) E. coli (n = 10) showed no specific adhesion patterns.
CONCLUSIONS:
E. coli isolates were highly diverse. Commensal and pathogenic isolates can adhere in various forms, including diffuse distribution, microcolonies, chains and clumps. Microcolony formation seems to be a global adhesion strategy also for commensal E. coli.