Accepted abstracts: Oral presentations

CASE REPORTS.

 

Title: (Accident…aloma) squared -Regarding a case on quaternary prevention.
Authors: Sofia Vale Pereira, Ana Pinho Lopes, Sophia Martins, José Assis Viveiros, Sara Dinis, Ana Leon Mota.
Keywords: quaternary prevention; pulmonary lesion; occupational exposure; incidentaloma.

Abstract: Quaternary prevention is a concept present in our daily practice and with overwhelming patient lists and lack of time we see ourselves falling into this trap of diagnosing incidentalomas and treating non-diseases, inducing alarmism, iatrogenic procedures and patient stress. This scenery paints the picture of “Disease Mongering” or “Sickness Phenomena”.

Man, 40 years old, asymptomatic, belonging to a unitary family (Graffar scale: I; Apgar 3). Presents with history of trauma, 18 years ago, that left him tetraplegic for 10 years, having recuperated to paraplegia in the last 8 years. In his first contact with his family physician, a regular physical examination was performed, and due to his family history of cancer, exposure to toxins – tobacco (26UMA) and chemicals – and low thoracic expansion, a routine workup and chest X-Ray was performed. This exam revealed “oval opacity projection, 1.6 cm; in middle region right hemitorax, regular and well defined limits to be studied.” In light of this a pulmonary CT scan was requested, having revealed:”in the anterior segment of middle lobe, nodular lesion with irregular and spiculate contour that must be studied and eventually accomplished with biopsy”. In his laboratory results an anemia was diagnosed. He was then rapidly referenced to Pneumology department. Despite having been submitted to various laboratory analyses, another CT scan, elective transthoracic biopsy (TTB), which complicated in pneumothorax and a Positron Emission Tomography PET/CT scan, no clear diagnostic direction was achieved. Pneumologist referenced to the department of Cardio-thoracic to perform a thoracotomy, with pulmonary wedge resection. The extemporaneous biopsy reveal benign tertiary justapleural lymphoid tissue in case, bronchus-associated lymphoid tissue (BALT) hyperplasia.

This case reflects some of our struggles in family medicine, having to balance decisions on probabilities and a few leads. This patient didn ́t present complaints but his family history, past traumatic experience combined with his exposures led the physicians to practice defensive medicine with various exams, some duplicated, and procedures that led to a benign discovery. We can ́t begin to imagine the anxiety and reduced quality of life provoked on this patient, during this episode. We must, then, ask ourselves if we proceeding in the best interest of our patients or if we are feeding into our own uncertainties and creating more “worried wells”.

 

Title: Importance of domiciliary visits for polypathological patients.
Authors: Ana Cláudia Monteiro Pereira, Cláudia Ho.
Keywords: home visits.

Abstract: Context: Nowadays, more and more people suffer not only from one pathology, but from several ones, which cumulatively contribute to their morbidity. Also, we reach a time where people could live longer but not as they wish to live or with dignified quality. As family doctors, we must seek better strategies to help them live their lives with quality and fulfillment of their wishes, trying to understand their families, environment and agenda.

Case Report: 80-year-old man, retired, married, partially dependent on the activities of daily living, with a syndromic biotype: short stature, multiple face fibromas and severe congenital ciphoscoliosis which he overcame during the years and proved himself that he could be sucessfull in life. At his 60’s, it became severe enough to conditionate respiratory failure and his mobility capacity due to pain. Also, he was diagnosed with type II respiratory failure, moderate obstructive sleep apnoea, arterial hypertension with complications - stroke in 2014 with decreased left hemibody strength as sequelae, adrenal tumor (he refused to do a biopsy and further investigations), diverticulosis, moderate mitral stenosis, right bundle branch block, benign prostatic hyperplasia, hypoacusia, depression, social isolation and history of falls. He was also investigated for possible Crohn's disease and neurofibromatosis. Currently, the adrenal tumor grew from 47x37mm to 59x77mm, for which he still refuses biopsy and surgery, he needs ambulatory oxygen and he is under respiratory rehabilitation.

It was through the domiciliary visit that we we’re able to find his main difficulties, different from those purely clinical, and that we could perceive his past, the way he faced and fought for all his life and the alternatives he found to feel good and live with quality. Rather than insisting on a treatment or on an exhaustive investigation, it is important to insist on the best way to meet his wishes and seek for his well-being.

Discussion: When we meet a patient with these characteristics it becomes crucial to know not only his clinical history, but also his biopsychosocial environment. Home visits are a good way to achieve this involvement, so important in family medicine. The follow-up of a patient with polypathology and multi-morbidity has its own characteristics and often the patient’s agenda differs from ours. Therefore, it’s key not only to use the available tools to evaluate family and social risk, but also to assess patient satisfaction.

 

Title: Two cases of “not so innocent” back pain.
Authors: Eduarda Cerdeira, Joana Queiroz-Machado, Abílio Malheiro.
Keywords: back pain; evidence-based medicine.

Abstract: Introduction: Back pain is one of the most common reasons for medical consultations. Some cases can be related to systemic disorders. The red flags for further investigation are well described in several guidelines, including those about prescription of spine computed tomography (CT).

Description: (Case 1) Female, 64 yo, caucasian. Married, accountant. History of high cholesterol. Current medication: rosuvastatine 10mg. Observed on 4-4-2017, reported mechanical diffuse middle back pain for two weeks, with associated muscle contracture. Diagnosed as common back pain, prescribed NSAIDs and rest. Visited again, four times in a month, for persistent pain (intensity 4-6/10) CT showed vertebral haemangioma on T8, no other significant problems. Combined tramadol/NSAID was prescribed. On 3- 5-2017, she called emergency due to sudden lower limb paraparesis. On emergency room, stroke was excluded, and CT showed pleral effusion and a conglomerate of mediastinal ganglia suitable for lymphoma, also liver and spleen enlargement was found. Admitted on Heamatology for further diagnosis and treatment. She died at the hospital on 7-7- 2017.

(Case 2) Male, 58 yo, caucasian. Truck driver. History of high cholesterol, colonic tubular adenoma removed on 2015, seafood allergy. Observed on 5-7-2017, reported lumbago for two weeks, no pain relief with oral diclofenac. Noctunal back pain, pain intensity 4/10, worsened with movement. Physical exam with no signs of radiculopathy. Prescribed tramadol/paracetamol and NSAIDs, lumbar spine x-ray. 9 days later he reported uncontrolled pain, irradiating now for both lower limbs. X-ray showed spondylo disc artrosis on T11-12 and L2-L4. CT followed. Quick clinical worsening reported with fatigue and weight loss, so he went to emergency room. Haemolitic anemia was diagnosed (Hb 5,8 g/dL), so he was admitted on Internal Medicine for further study. Cancer of unknown primary origin was diagnosed, most likely a gastric carcinoma with bone metastasis. He died at the hospital on 10-8-2017.

Conclusion: Although red flags for severe causes of back pain are well described, sometimes it is difficult to quickly recognize them at primary care practice. Evidence-based guidelines on this topic should support the individualized medical care.

 

 

Title: Piriformis syndrome: a form of non-discogenic sciatica.
Authors: Sara Coelho, José Eduardo Mendes, Carolina Gil.
Keywords: sciatica; piriformis syndrome.
Abstract: Introduction: Piriformis syndrome is a neuromuscular disorder related to the sciatic nerve, characterized by its compression through or around the piriformis muscle. Classically it presents as sciatica, with pain in the gluteal region that radiates along the lower limb, and is secondary to dysfunction of the piriformis muscle - non-discogenic. Like classic sciatica, it worsens with gait, running, squatting, and sitting and the intensity varies throughout the day, with asymptomatic periods. In the physical examination there is no neurological deficit and the straight leg raise test (Lasègue) is usually negative. Diagnosis is often difficult, and it is one of exclusion due to few validated and standardized diagnostic tests, compromising its definition.

Clinical case: A 48-year-old man presents with complaints of pain in the left thigh and hip, irradiating down the outside of the thigh and leg to the distal third of the leg, with months of evolution. It relieves with physiotherapy program, non-steroidal anti-inflammatories and laying down. It worsens in the sitting position. At physical examination there is no back pain during observation, and the straight leg raise test is negative, but there is tenderness over the gluteal region, and during flexion, adduction, and internal rotation of the hip. A CT scan of the lumbar spine was requested, which revealed no changes. The patient will meet new physiotherapy treatments. We also advised to perform regular physical activity, with stretches directed to the piriformis muscle.

Conclusion: Piriformis syndrome consists of a neuropathy due to compression of the sciatic nerve in the vicinity of the piriformis muscle, being a form of non-discogenic sciatica. Although it is a clinical entity well described in the literature, it still lacks validated and standardized diagnostic criteria and treatment. Thus, it requires the knowledge of the clinical presentation and the systematized exploration for suggestive signs. The course of the disease is generally favourable after analgesic and/or anti-inflammatory therapy and physiotherapy. Given the high prevalence of sciatica in clinical practice, it is important to consider this diagnosis in its approach, not only to avoid an exhaustive investigation to study presumed discogenic sciatica, but also to properly diagnose this syndrome and institute therapy.

 

Title: The psychological impact of infertility.
Authors: Natalina Rodrigues, Cristina Serra, Miguel Pereira.
Keywords: infertility; psychological stress.

Abstract: Introduction: The impact of infertility can lead to psychopathological manifestations that condition marital, family and social lives. The stress caused by the inability to conceive children, combined with the demands of the whole process of diagnosis and treatment, leads to high levels of stress that easily aggravate anxious and depressive disorders.

Case Description: A 37- year-old female, married, shop assistant and belonging to the middle class by the scale of Graffar. Past history is remarkable only for depression medicated and regularly followed in psychiatrist, with no history of gynecological problems. The patient reports good health and no problems were found at pre-conceptional study in 2010. Due to her difficulty in getting pregnant over a year, she was sent to the infertility clinic. The study carried out at the clinic reveled inflammation of the fallopian tube and her husband (with Crohn Disease) presented hypomotility of the spermatozoa, therefore the couple began treatment with medically assisted procreation techniques as in vitro fertilization and embryo transfer. After treatment failure in 2012, she began with recurrent episodes of anxiety, worsening of her depressive disorder and nonspecific complaints (abdominal pain and headache). In 2015 she resumed new fertility treatment that failed as well thus presenting her first panic crisis. After this failed treatment, there was a further worsening of the anxious situation and the frequency of panic attacks, but presented new symptoms such as weight gain, palpitations, syncope and dizziness. She performed cardiac, analytical and imaging studies that diagnosed an autoimmune thyroiditis. Since 2016 she had multiple appointments with her family’s physician due to work disability caused by her depressive illness and panic attacks. In June, after an episode of vulvovaginitis, the patient initiated pelvic pain and migratory arthralgia of the large joints. Posterior analysis shown increased Sedimentation Velocity and C-reactive protein. She was then referred to autoimmune diseases specialty.

Discussion: The present case report, show how infertility generates a range of feelings, such as distress, depression, panic disorder and social exclusion. However, even the treatment to infertility can be associated with some important symptoms. This clinical condition decreases the quality of life and directly affects the relationship between the couple, family and the work environment.

 

Title: Thyroid autoimmunity and postpartum affective disorder: causal relationship or not?
Authors: Marta Barroca, Diogo Coelho Correia, Susana Pacheco.
Keywords: thyroiditis, autoimmune; depression, postpartum.

Abstract: Background: Immunologic tolerance justifies the favorable evolution of autoimmune thyroid diseases during pregnancy and explains their exacerbation in the postpartum. Postpartum thyroiditis affects 4-10% of women up to 12 months postpartum, presenting as asymptomatic, with symptoms and signs of hypothyroidism or hyperthyroidism. In the later scenario, differential diagnosis with Graves' disease is clinically difficult, so positive anti-TSH receptor antibodies (TRABs) confirm this diagnosis. Maternal thyroid autoimmunity is still related to postpartum depression, a situation that should call for the attention of family doctors while they provide care to newly mothers.
Description: 34-year-old female, nuclear family in phase III of Duvall's life cycle, 2 daughters (5 years and 12 months-old), teacher. Past smoking history, hyperemesis gravidarum in both pregnancies, Graves' disease after the first pregnancy – in remission and without therapy since 2014. 7 months after the second delivery she presented symptomatic hyperthyroidism and thyroid evaluation revealed positive TRAbs, which confirmed the recurrence of Graves' disease. She initiated therapy with thiamazole and propanolol, wich was effective in controlling thyroid function about 1 month later, requiring therapeutic adjustment with levothyroxine. However she maintained marked irritability, sadness, lack of concentration and insomnia, with great impact on her relationship with her husband and daughters. After careful anamnesis we realized that this emotional lability were present since the first delivery, although lightly. She started escitalopram and zolpidem, with little efficacy, and the case was discussed with our psychiatry consultant, who suggested further evaluation in psychiatry consultation - for which the patient is presently waiting. Discussion: Although there is an association between hormonal imbalances of the postpartum period (including thyroid hormones) and affective disorders, in this patient's particular case the causal relationship is not clear. Careful details of her anamnesis suggest that a psychiatric condition has been evolving in the past few years, though aggravated now by her hormonal alterations. At the same time, the recurrence of an autoimmune thyroid disease requires a differentiated support by endocrinology. In these cases, the family physician acts as a liaison and point of continuity of care for the patient, performing a watchful monitoring, early diagnosis and rapid referral.

 

 

 

PRACTICE REPORTS. 

 

Title: To be a Family Doctor beyond the Atlantic.
Authors: Ana Margarida Gomes, Ana Rute Marques.
Keywords: Brazil; family medicine; family doctor; exchange.

Abstract: Introduction: Because exploring the reality of Family Practice (FP) in other places is essential, we participated in an exchange program at a Health Center (HC) in Rio de Janeiro (RJ). Brazil is a close relative of Portugal but it has its own epidemiological, organizational e cultural particularities. Therefore, we thought this was a unique opportunity to acquire new professional and personal skills. Objectives

To state the differences between the Brazilian health system (BHS) regarding the way Primary Care (PC) works and how applying them to the Portuguese PHC could be relevant;

To enhance the importance of multidisciplinarity and community interventions in FP;

To create an international bond, facilitating the residents’ training and the exchange of experiences. Relevance

To partake in team efforts of caring for the community and to instigate the experiences exchange beyond borders is relevant to the medical training, especially in FP.

Description: Since 2009, with the “Family Health Strategy”, RJ went from a population coverage of 3,5% to 70%, having the family doctor (FD) a key role in the evolution of PC.
The BHS is similar to the Portuguese healthcare system regarding its core competencies in FP. Yet, there are important structural differences. The HC have
a pharmacy, dental offices and complementary exams. The health team is multidisciplinary thanks to the Family Health Support Nucleus (FHSN) composed of psychologists, dieticians, physiotherapists, physical educators, occupational therapists and social workers. The Community Health Agents (CHA) contribute to facilitate the activities in the community and personalized domiciliary visits.

Discussion: Although it’s an evolving model, it is supported by a strong foundation regarding teamwork and the holistic approach of the patient in its community. To this end, the multidisciplinary health teams play a critical role.

To have taken part in this reality allowed us to reinforce the importance of PC and the essential role of the FD in close articulation with other professionals. Our goal is to share this knowledge with our peers, making a contribution to the enrichment of the daily clinical practice.

Conclusions: To have witnessed first hand the activities of the professionals in a HC in RJ, particularly the work of the FD in the BHS was very beneficial. The attentive study of its particular characteristics was also a plus both to our individual growth and to the reinforcement of the essence of working as a team.

 

Title: Childhood obesity: experience in a primary care setting.
Authors: Susana Rita.
Keywords: pediatric obesity; primary care.

Abstract: Introduction: childhood obesity is the most prevalent chronic pediatric disease, affecting 43 million children worldwide. Its numerous consequences include depression and diabetes. Being a preventable disease, with both social and a familiar components, it is an important diagnosis in primary care.

Purpose: to describe the 17-month experience with childhood obesity in a primary care setting – USF Samora Correia.

Description: between June 2015 and October 2016, we consulted 52 children with obesity. 32 returned for follow-up appointments, while 20 patients either dropped-out, missed the next appointment, or were discharged. Out of those who remained in our care, 11 were female and 11 were male, with an average age of 9 years. 4 cases began before the first year of life, 13 cases between 2 and 5 years, 10 cases between 6 and 9 years and 5 cases between 10 and 18 years of age. An inadequate diet was the main factor found to be responsible, with only 2 cases attributed to a secondary etiology. Familiy history most commonly revealed cases of obesity (20 cases) and cardiovascular diseases (28 cases) in close relatives. 22 cases observed a steady improvement in the BMI. The most prevalent comorbidities included vitamin D deficiency (16), hyperlipidemia (6), insulin resistance (4), mental disorders (4) and hepatic steatosis (2). Only 7 children had no comorbidities.

Discussion: we observed an important familial component in the etiology of childhood obesity, which was most frequently diagnosed in preschool children. Most cases responded positively to our individualized approach, with an improvement in BMI. The most frequent comorbidities found likely have an additional negative impact in bone metabolism and risk of cardiovascular diseases. Conclusions: childhood obesity is a major disease in the daily practice of the family physician, with a potential impact in the psicossocial development of children, as well as their future risk of disease. An individualized approach to these patients in primary care is able to successfully identify and manage the most frequent factors involved.

 

Title: Challenges in primary care practice when dealing with older people.
Authors: Gergana Foreva, Radost Asenova, Pepa Ferreira, Kiril Elenski.
Keywords: primary care practice; older people; geriatric consultations; patient education.

Abstract: The number of older people is growing rapidly in Bulgaria. The current health care

system does not acknowledge their specific needs. Problems such as recurent falls, polypharmacy, cognitive impairment, social isolation remainy unrecognised for a long period of time and show themselves in health and/or social crises. The aim is to present a model of early intervention in primary care. Our general practice has a list of 4200 patients. Despite of older people being approximately 20%, they consume around 50% of the general practitioner's time. The model, presented here, consist of specialised geriatric consultations and educational sessions for patients and their relatives. Our goal is to help older people to maintain their health and independence.

 

Title: Eating healthy and mindfully while pregnant.
Authors: Sara Andrade, Cristina Bastos.
Keywords: healthy diet; pregnancy.

Background: Introduction: Maternal Nutrition in pregnancy and lactation is of considerable interest to women, their partners and their health care professionals. Poor maternal diet in theses stages of life is a potential threat to maternal and child health. There is no doubt that a nutritious, well-balanced eating diet can be one of the greatest gifts that a mother can give to herself and to the developing baby. Mindful eating, a method of eating with awareness, also seems to be a way of achieving adequate nutrition and weight gain for pregnant women.

Some reports show that that these groups are not appropriately consuming foods for their physiological status and reinforce a real need for improved education and community outreach programs.

Aim: This practice report pretends to present the work that we are doing with pregnant women that are participating in Parenthood Preparation courses of our Health Family Center. We are developing nutrition group sessions with the purpose of promoting informed dialogue about nutrition, improving nutritional knowledge and encouraging healthy nutrition in pregnancy and lactation.

Description: The nutrition group sessions are being conducted by a general and family medicine resident who practiced nutrition prior to entering medical school. The themes included are: weight during pregnancy and lactation, nutritional myths and facts, macronutrients and micronutrients, food safety, tips to healthy cooking, ways to practice mindful eating. These sessions have an interactive and practical component, with realistic exercises, and provide a safe environment to ask questions and learn from others.

Discussion/Conclusion: During pregnancy and lactation women become more aware of the importance of healthy nutrition and seek for more nutrition-related information. A nutritional education intervention will have a positive effect on pregnant and breastfeeding women nutrition. It will help them to make better choices and enable them to improve their eating habits and their future child nutrition.

 

Title: Missing in the ladder.
Authors: Yusianmar Mariani, Elena Klusova, Sara Rigon, Özden Gökdemir, Nina Monteiro, Ana Nunes Barata.
Keywords: gender diversity, salary gap, equity.

Abstract: Topic to be explored: The long-term and controversial unequal career advancement between genders.
There is a well known history of inequity on professional success between women and men where women’s participation to political, economic, professional and social life has been significantly limited by social norms. The most recent Financial Times Stock Exchange 100 Index reports that only 20 per cent of international assignees are women — a number that has barely shifted for more than a decade and this has not been different in the healthcare industry where has been proved how hard is for women to climb to the top of the ladder when there are rungs missing further down.
Why the topic is of likely interest: Gender equality is intrinsically linked to sustainable development and is vital to the realization of human rights for all. The reality is that as well in another industry, the facts are similar in the healthcare sector and changes on this are yet to be made, so the society urge to make some progress to improve the numbers of female health care leaders as well as their impact on the field. By exploring and discussing the main barriers and issues related with this topic i.e: gender roles, stereotypes, family life and international policies, we aim the participants could reflect on it and came up with practical/possible ideias to be applied. We hope the attendees would able to inspire the primary health care community to break free of old paradigms and rethink its structure towards a future of equal opportunities and professional success regardless of gender.

 

Title: A Travel Medicine Clinic in Primary Care - a new challenge!
Authors: Ana Costa.
Keywords: travel medicine; tropical medicine; global health.

Abstract: Travel Medicine is an emerging discipline whose main focus is travelers health promotion, and personal safety, as well as the prevention of infectious diseases, and those related to important environmental risks. In Sintra, Portugal, there was a manifested need for the development of a regional Travel Medicine Clinic within primary care, given the rising numbers of travelers, many of whom are immigrants from tropical countries and often travel home to visit their families. Given my interest in this sub-specialty and global health, and having formal training in Travel Medicine, I was asked to join a small team of professionals in establishing a travel clinic in a Family Health Centre in the Sintra region, to serve the needs of the community.

Objectives: To describe our practice, in terms of context, population, team, our main objectives and outcomes, our importance in the community, as well as our future aspirations

Relevance: Our practice demonstrates how travel medicine can be well developed as a subspecialty by family doctors, providing the service in Primary Care. After acquiring the necessary specialized training in this area of medicine, we as family doctors are well positioned to provide this service at the community level, given our knowledge of the population we serve; our holistic vision in providing care; our ability to deal with multiple co-morbidities which is essential in the context of travel medicine; and our accessibility which will improve access to pre-travel consultation.

Description of our practice: Our travel clinic opened in October 2016 at USF AlbaSaude in Sintra. The team is comprised of 2 doctors and one nurse. The pre-travel consultation consists of a global risk assessment, vaccination, and health education and promotion. Special areas of focus are viral infections and those transmitted by mosquitos; STDs; travelers diarrhea; malaria prophylaxis; altitude sickness; and accident prevention. We developed an internal referencing system for the Sintra region, through an online form which reaches us electronically.

Conclusion: We are a perfect example of how travel medicine can be decentralized and provided in the primary care setting, thereby increasing access to the community and increasing adhesion to pre-travel medical advice. This will not only have an impact on the health of our local population but on the global transmission of diseases and on morbidity and mortality.

 

Title: Presbyphagia: When eating becomes hard to swallow.
Authors: Joao Ribeiro, Sandrina Rodrigues.
Keywords: deglutition disorders.

Abstract: Introduction: presbyphagia can be defined as any changes in swallowing oral, pharyngeal or esophageal phases that happens in the healthy elderly as a result of the natural aging process. According to a study carried out in 2012, presysphagia prevalence in the elderly can be as high as 68%, so active attention by the Family Doctor is essential to detect it at an early stage. As the Speech Therapist is the professional with greater ability to diagnose and treat this problem, it would be beneficial to share experiences in order to learn and improve screening techniques that could be applied in Primary Health Care, as well as to understand how an intervention is carried out in this patients.

Objectives: To make a practice report of a partnership between Family Doctor and Speech Therapist in order to guarantee presbyphagia early detection.

Relevance: Due to the growing number of elderly population, it's extremely important to recognize alert signs that raise suspicion of presbyphagia, as well as some informal screening tests that can be applied in Primary Health Care that detect presbyphagia at an early stage.

Description: As we were developing this project, it has been possible to attend with a speech therapist in order to better understand some alert signs and symptoms of a possible oropharyngeal dysphagia. It was also possible to observe and train the application of screening tests in patients who presented some of these signs and to observe how an early intervention is performed in situations of presbyphagia.

Discussion: Family Doctors has a very important role in early detection of many problems that may endanger our patients’ health. Detecting presbyphagia, that can lead to serious consequences, as early as possible, we can make the difference in patients quality of life, turning also possible to avoid situations that harm our patients, whether due to affecting quality of life (considering that "eating" is a social act) as problems that can lead to several uses of the emergency service and even endanger patients life, such as aspiration pneumonia.

Conclusion: It’s important sensitize Family Doctors to presbyphagia and warning signs and symptoms. The exchange of experiences with the Speech Therapist allows to sensitize and better know the needs and how to help patients with presbyphagia. It would be importante to Family Doctors to know and to apply some screening methods in order to early detect this frequent but often neglected health problem.

 

Title: How can GPs talk about sex?
Authors: Carla Rodrigues, Andreia Silva, Ana Filipa Vilaça, Helena Marques, Sara Rita, Ana Beatriz Figueiredo.
Keywords: GP; sexuality; consultation.

Abstract: According to the World Health Organization, sexuality is a key aspect of the human being, encompassing sex, gender identity, sexual orientation, eroticism, intimacy and reproduction. Sexuality is broader than the individual experience of sex and it can and should be addressed on consultations as part of a person-centered medical approach. Despite the elevated prevalence of sexual related problems, Sexuality-related Communication (SRC) is often neglected by the General Practitioner.How can we do it and why are we so oblivious to this issue? Are we prepared to do so?Pre-graduate training is scarce and heterogeneous between the profusion of Medical faculties. Post-graduate training is expensive and mainly focused on dysfunction rather than functionality or part of a relationship.Nevertheless, patients expect their doctors to address the topic and studies show that sexual health concerns may never be voiced if the patient is left with the responsibility to introduce it. The lack of comfort, the reluctance to talk about sexuality or the fear of offending the patients limits our performance and makes SRC less clear or objective than it should be, decreasing our ability to educate our patients regarding Sexual Health.Sexual health should be a cornerstone of preventive medicine. In order to improve our skills we must bring SRC to light, face our limitations. Only then we’ll be able to enhance our performance on consultation and create strategies to improve our quality of care to populations.

 

Title: Emergencies in Primary Care in Spain for immigrant population.
Authors: María Belén Arellano-Cobos.
Keywords: emergencies; primary care.
Abstract: Spain is one of the southern european countries that welcomes retired people from other european countries. Adapting to a new country implies adapting to a new healthcare system, apart from difficulties related to the new language. How is the spanish healthcare system? Where should you go in case of emergency? What is the telephone number for an extrahospitalary emergency? Educating immigrant population about the knowledge and use of the spanish public healthcare system should be a priority for Family Doctors. A thirty-minutes oral presentation was performed by a resident of Family Medicine in a rural healthcare centre for a population of fifty people coming from the United Kingdom. Afterwards, attendants were allowed to make questions and solve their doubts. The oral presentation was totally performed in English so as to avoid the barrier of the Spanish language for immigrant population. Important topics such as how to recognize a myocardial infarction or how to proceed in case of fever in a patient recibing chemotherapy were explained by using slides. As a result, the immigrant community coming from the U.K. living in the town of St. Bartholomew (Orihuela-Alicante) learned how to recognize life-theatening diseases and where to find the most suitable medical care in Spain.

 

 

 

QUALITY STUDIES. 

 

Title: Reducing the risk of blood borne infection through sharps injury in a non-governmental organisation in India.
Authors: Amy Dehn Lunn.
Keywords: needlestick injury; healthcare workers; occupational exposure; accident prevention; blood borne pathogens.
Abstract: Background: Healthcare workers handling sharps are at risk of blood borne infections such as HIV, hepatitis B and hepatitis C. A needlestick injury witnessed in a non-governmental organisation delivering primary care in Kolkata, India led to a programme to reduce the risk of blood borne infection through occupational exposure to healthcare workers.

Baseline audit: Sharps handling was audited over one week. Phlebotomy is carried out by external staff; all other sharps handling by the organisation’s staff. 35 episodes of phlebotomy and intramuscular injections were observed. Gloves were not worn for any episode. Recapping of needles occurred in all episodes. 10 episodes of scalpel use in wound care were observed: gloves were worn on all occasions. Sharps bins were available in all clinics. Staff had a sharps bin within reach in 85% of sharps handling episodes: 90% (18/20) of blood sampling, in 66% (10/15) of intramuscular injections and in all (10/10) wound care episodes. A survey revealed that only 57% of the organisation's staff members handling sharps (9/21) were immunised against hepatitis B.

Interventions A staff training programme and protocol for the safe handling of sharps were implemented. External phlebotomists were invited to training but did not attend. A hepatitis B immunisation programme was started. A protocol for the management of body fluid exposure was implemented. A reporting system was established for occupational exposures, and training on its use was given to clinic managers and doctors.

Post-intervention audit: Practice was observed over one week one month post-intervention. Gloves were worn 80% of the time (all intramuscular injections and wound care and 39% (11/28) of blood samples). Needle recapping was observed in 35% of episodes (10% (2/20) intramuscular injections and in 60% (15/28) of blood sampling). Sharps bins were to hand in 93% of sharps handling episodes: all phlebotomy (28/28) and wound care (8/8) and 80% (16/20) of intramuscular injections. 89% (8/9) unimmunised staff members had commenced hepatitis B immunisations.

Conclusions: The project revealed a range of safety issues around sharps handling within the organisation. Post intervention, marked improvements in practice were seen (e.g. needle recapping reduced from 100% to 35%). Hepatitis B immunisation of healthcare workers at risk improved from 57% to 95%. This project demonstrates that a low cost series of interventions can have an important impact on staff safety.

 

Title: Quality improvement in antibiotic prescription for uncomplicated lower urinary tract infections.
Authors: Ana Luisa Marcelino, Cátia Barão, Ana Isabel Silva, Candida Teixeira, Mariana Carvalho, Sara Santos.
Keywords: low urinary tract infections.

Abstract: Introduction: Lower urinary tract infections (LUTIs) are the 2nd most common bacterial infection in the community and the most common bacterial agent is Escherichia coli which has a high resistance rate to quinolones and sulfamethoxazole/trimethoprim. Portuguese national guidelines for primary healthcare are: nitrofurantoin, fosfomycin and amoxicillin/clavulanic acid. Objective: Assess guideline adherence for the empirical treatment of uncomplicated LUTI in primary care and the impact in prescription quality after local intervention. Methods: we stablish 3 groups to study, group A before intervention, group B studied 10 days after intervention (awareness and information of primary care doctors) and group C was study 3 months after intervention. The sample included patients from 5 primary healthcare units in the westcoast region of Portugal diagnosed with uncomplicated LUTI. The search was made based on the electronic medical record system on ICPC-2 (International Classification of Primary Care). Discussion: The sample size was similar between the three groups. Fosfomycin was the most prescribed antibiotic drug. The rate of guideline adherence for the empirical treatment of uncomplicated LUTI was high in all 3 groups (Group A: 81.8%; Group B: 79.1%; Group C: 76.4%). After the intervention, the prescription rate of ciprofloxacin decreased, and this effect was mantained after 3 months. On the other hand, the prescription rate of other antibiotics (other than the first line drugs) increased. The study had some limitations, such as: was not possible to determine with certainty if the treatment prescribed was in fact empirical or either directed by results of antimicrobial susceptibility testing; study period might have been short; we were not able to assess the efficacy of the antibiotic treatment. Conclusion: Guideline adherence for the empirical treatment of uncomplicated LUTI is high and our results were superior to those described by similar national studies. The local intervention had no impact toward a higher guideline adherence. Ciprofloxacin and other antibiotics continue to be significantly prescribed.

 

 

 

RESEARCH STUDIES. 

 

Title: Determination of the factors and perceptions which affect the health behaviour of women: a qualitative research from Turkey.
Authors: İkbal Hümay Akyildiz, Elif Demirtaş Okumuş, Nan Je Lay, Kader Topçu, Özlem Sarıkaya, Pemra Cöbek Ünalan.
Keywords: women's health; perception; unmet needs; Turkey.

Abstract: Aim: To determine the perception, behaviors and expectations about health and sickness of women from our society, and to evaluate the socio-cultural characteristics of these behaviors.

Method: This research is qualitative and criterion sampled. The research universe was 31 women who are aged between 17-77 and have different socio-cultural characteristics. 4 focused interviews were conducted. The researchers gave information about the topic and method before meeting. Participants filled a questionnaire for demographic characteristics. The interviews were made face-to-face at the participants’ houses. There was one interviewer and two observers in each session. The voice recordings and the observers’ notes of every interview were trasncripted. No names have been transcripted. Each of the interviews were analyzed thematically, then some of the themes were commonised and research findings were reached.

Results: According to the analysis, there are five theme topics. These are; 1-physician (professionalism) characteristics affecting the choice of doctor (skills, attitude, gender, knowledge, etc.), 2-emotions and thoughts about women’s health care services (shame-embarrassment, unable to choose a doctor, examination style, no need, etc.), 3-reasons for choosing health institutions (attitude of health workers, gender of doctor, hospital facilities, dental services, accessibility, prejudices, long waiting hours, etc.), 4-unmet health needs and perceptions of the causes (Anxiety, fear of malpractice, crowd, long waiting hours, community prejudices), 5-thoughts about Family Health Centers (mistrust, lack of equipment,doctor’s attitude).

Conclusion: The sociocultural characteristics that determine the perception of the individual, the health care system and the problems caused by the health care workers, significantly affect the individual's utilization of the health care service. Health care workers need re-education or reorganization and health system needs reform with guidance of these factors, which affect health perception and especially for unmet needs of health care for women. To emphasize patient centered approach continuously may be necessary for improvement.

 

Title: Core Content Classification in General Practice/Family Medicine (3CGP). A New indexing system for General Practice Knowledge management.
Authors: Marc Jamoulle, Ariana Tavares, Susana Medeiros, Luís Miguel Santiago.
Keywords: osteoporosis; urban population; dual energy X-ray absorptiometry.

Abstract: Background: Sharing the results of research with General Practitioners (GPs) is crucial for the survival of the discipline of General Practice / Family Medicine (GP/FM). Usual indexation systems like MeSH are not multilingual nor adapted to the particular field of GP/FM. Consequently, the GP/FM abstracts are lacking bibliographic control and more than half of the research presented by GPs at congresses is lost. We propose a new multilingual indexing system. The existing International Classification of Primary Care (ICPC) has now been expanded with a taxonomy related to contextual aspects (called Q-Codes) such as education, research, practice organization, ethics or policy in GP/FM, currently not captured. The set is proposed under the name Core Content Classification in General Practice (3CGP).

Aim :The aim is to facilitate indexing of GP/FM specific scientific work and to improve performance in information storage and retrieval for research purposes in this field.

Research Method/Procedure: Using qualitative analysis, a corpus of 1,702 abstracts from six GP/FM-related European congresses was analyzed to identify main themes discussed by GPs, handled in a domain-specific taxonomy called Q-Codes and translated in 8 languages. In addition, a methodology for building a lightweight ontology (in OWL-2) was applied to Q-Codes, adding object and datatype properties to the hierarchical relations, including mapping to the MeSH thesaurus, Babelnet (www.babelnet.org) and Dbpedia. Finally, the ICPC-2 in 19 languages and Q-Codes in 8 languages have been integrated in a healthcare terminology service (www.hetop.eu/q) with a companion website (http://3cgp.docpatient.net)

Anticipated results of the research: Through better indexing of the grey literature (congress abstracts, master's and doctoral thesis), we hope to enhance the accessibility of research results of GP/FM domain and promote the emergence of networks of researchers. First result of experimental implementations of the new indexing system will be presented. The Brazilian congress of family and community medicine 2017 has been entirely coded by participants with ICPC and Q-Codes and 1746 accepted and coded abstracts are ready to be analyzed and will be discussed. In Portugal 300 master theses have been coded with Q Codes and the result will be also presented and discussed.

 

Title: Modifiable risk factors for dementia.
Authors: Sofia Santos, Ivone Rodrigues, Maria Teresa Tomé, Emilia Nina.
Keywords: dementia; risk factors.

Abstract: Introduction: With the ageing of the population, there has been an increase in dementia prevalence, a condition that leads to a significant disability without any disease-modifying treatment.
There are 9 potentially modifiable risk factors (RF) for dementia that, if effectively treated/managed, can prevent 35% of dementia cases. These RF are divided between the different phases of the life-span in which intervention is more important. The most important RF in midlife (45-65 years old) are hearing loss, hypertension and obesity. However, in later life (>65 years old) this importance shifts to smoking, depression, physical inactivity, social isolation and diabetes. Due to its prevalence and significant number of modifiable RF, dementia has an increasing role in the clinical practice of the Family Doctor. Intervention and prevention in this area can lead to important gains in quality of life.

Objective: To identify the prevalence of modifiable RF for dementia in a population with #45 years old.

Methods: Study: cross-sectional.
Population/Sample: patients with #45 years old followed in a Health Unit.
Exclusion criteria: dementia, developmental delay, neurological infection, neurological tumors and multiple sclerosis.
Study variables: hearing loss, hypertension, obesity, smoking, depression, physical inactivity, social isolation and diabetes.
Data source: clinical information obtained from MedicineOne@.
Data analysis: Microsoft Office Excel 2013@.

Results: We found 4628 patients between 45-65 years old, from which 35 were excluded. In midlife, 808 patients (17,6%) had hypertension, 613 (13,3%) obesity and 56 (1,2%) hearing loss. In midlife, 1183 patients (25,8%) presented at least 1 RF.
We found 3456 patients >65 years old, from which 141 were excluded. In later life, 622 patients (18,8%) had depression, 601 (18,1%) diabetes, 168 (5,1%) physical inactivity, 157 (4,7%) smoking habits and 24 (0,7%) social isolation. In later life, 1306 patients (39,4%) presented at least 1 RF.

Discussion: The Family Doctor has a privileged role in disease prevention, with detailed evaluation of RF and available resources.
There is a significant preventive potential in our population. Between 45-65 years old, a good intervention in hypertension and weight control is essential. In later life, effective diabetes control and depression treatment is very important. Despite the importance of intervention in these key age groups, all of these RF must be frequently and effectively evaluated/controlled.

 

Title: Total energy intake and dietary risks associated with the use of alcohol among urban Sri Lankan adults.
Authors: Nishan Silva, Shaluni Tissera, Pasindu Malaka, Thusitha Bandara, Geethanjana Malsha.
Keywords: calorie intake; alcohol consumption; alcohol and calories; alcohol NCD risks.

Abstract: Introduction: Evidence suggests that moderate amount of alcohol intake (14 units per week) reduces the risk for type 2 diabetes and heart diseases. But, Sri Lanka being a country with its own food habits and practices, calorie intake associated even with the recommended alcohol amounts, puts the appropriateness of the above recommendations to doubt.

Objectives: To identify the calorie intake for a unit of alcohol and to identify food patterns in related to alcohol consumption.

Method: Descriptive cross sectional quantitative study was done on 300 males and females who are consuming alcohol using convenient sampling method in the Gampaha District, Sri Lanka through a questionnaire.

Results: Among 261 eligible participants, mean age of the participants were 35 and mean BMI was 25.33 (over weight). Considering the mean values; on a drinking day, on average 14 units of alcohol is consumed and over a week at least 28 units are consumed in total. Nearly 234 kcal of food is taken with a unit of alcohol and approximately 27 kcal of chases are added to a single unit of alcohol. Majority of the participants (257) consume hard spirits mostly at al,average of 13 units per day. 36% of the respondents have cigarettes every time they consume alcohol and the mean usage of cigarettes in an average drinking day is 8.

Conclusion: Due to high intake of energy from food and chases when consuming alcohol, the recommended safe units of alcohol consumption given in western context cannot be applied to Sri Lanka.

 

Title: The effect on the patient flow in a local health care after closing a suburban primary care emergency department: a controlled longitudinal follow-up.
Authors: Katri Mustonen, Jarmo Kantonen, Timo Kauppila.
Keywords: distance; emergency department; primary care; suburban.

Abstract: Background. It has not yet been studied, what happens to patient flow to EDs and other parts of local health care system, if distances to emergency department (ED) services are manipulated as a part of health policy in urban areas.

Methods. The present work is an observational and quasiexperimental study with a control and is based on before-after comparisons. How terminating a geographically distant suburban primary care ED alters patient flow to doctors in local public primary care ED's, office-hour primary care, secondary care ED's and in private primary care was studied. The effect of this intervention was compared to another city and its primary care system where no similar intervention was performed. The number of monthly visits to doctors in different departments of health care was scored as the main measure of the study in each department studied (e.g. in primary care ED's, secondary care ED, office-hour public primary care and private primary care). Monthly mortality rates were also recorded.

Results. Increasing the distance to ED services by terminating a peripheral ED did not cause an increase in use of local office-hour services in those areas whose local ED was terminated, although use of ED services decreased by 25% in these areas (P<0.001). The total use of primary care doctor services rather decreased - after this intervention, while use of doctor services in secondary care ED remained unaffected. Doctor visits to the complementary private primary care increased, but this was probably not associated with the intervention because a simultaneous increase in this parameter was observed in the control city. There was no increased mortality in any age groups.

Conclusion. Manipulating distances to ED services can be used to direct patient flows to different parts of the health care system. The correlation between distance to ED and the tendency to use ED by

inhabitants is negative. If secondary care ED was available there were no life-threatening side-effects at the level of general public health when a minor ED was closed in a primary care ED system.

 

Title: Delayed antibiotic prescribing for respiratory infections.
Authors: Nuno Parente.
Keywords: delayed prescriptions; respiratory infections; antimicrobials resistance.

Abstracts: Context: Antimicrobials have revolutionized medicine. In the second half of 20th century as major contributors to life-expectancy increase. Today the level of resistance to antimicrobials is at its high and, accordingly to the European Centre for Disease Prevention and Control, 25.000 persons per year are infected with resistant bacteria. Besides, there's an estimated increase in health-related expenditures by 1.5 billion Euros. The inappropriate use of antimicrobials by healthcare professionals is the most significant factor perpetuating the resistance problem. Most of uncomplicated respiratory tract infections (uRTI) do not imply an antibiotic to improve its outcome, although the overprescribing is a reality.

Methods: It was performed a narrative review searching Pubmed, The Cochrane Library, University of York Centre for Reviews and Dissemination databases for clinical guidelines, narrative reviews, systematic reviews and meta-analysis combining the subsequent keywords: "antimicrobials", "antibiotics", "delayed prescri*". The search was limited to publications in English and Portuguese and dated from January 1, 2000 to August 31, 2017.

Results: Immediate antibiotic prescribing in uRTI only confers modest symptomatic relief comparing with delayed prescribing. Patients satisfaction was reported as high in both strategies. However, the antibiotic use is markedly lower with the delayed prescribing strategy (31% vs. 93%). Both strategies were similar on morbidity outcomes. The return for revaluation of clinical status resulted in the lowest antibiotic prescription rate.

Conclusions: There's some heterogeneity in studies design, mainly due to different antibiotics regimens and clinical presentations. Delayed prescribing was safe in terms of disease complications rate. Future research should focus in find the groups at higher risk, who truly benefit from antibiotics, and use a "no antibiotic" arm as comparison.

 

Title: Psychiatric and Psychosomatic manifestations on the skin: An approach to Psycodermatologic symptoms in the Primary Care Setting.
Authors: Gustavo Gomes Oliveira, Catarina Rocha Vieira, Cátia Lírio.
Keywords: psychodermatology; psychocutaneous medicine; psychiatric symptoms; psychosomatic symptoms; skin symptoms; skin diseases; primary care.
Abstract: Introduction: As both the skin and the CNS share the same origin from the embryonic neuroectoderm, physiological connections link the CNS functioning to the cutaneous expression. Dermatological symptoms can thus be a common sign of stress and psychiatric disorders. Despite their global crescent prevalence, patients still greatly resist to accept or acknowledge their psychiatric or psychosomatic symptoms, often withholding them from their physician. However, skin disorders, being visible and disturbing for the majority of people, represent one of the top causes of primary care consultation. Therefore, it’s fundamental for the physician to know and be able to recognize and suspect skin manifestations as a reflection of psychosomatic or psychiatric illness.
Objectives: Bibliographic research about symptoms and skin diseases as a reflection of psychiatric and psychosomatic illness and its approach in the primary care setting, highlighting the current diagnostic and therapeutic recommendations.

Methods: Bibliographical research on the Pubmed/Medline databases, with the keywords "psychodermatology", "psychocutaneous medicine", “psychiatric symptoms”, "psychosomatic symptoms", "skin symptoms", "skin diseases" and "primary care", for articles published until June 2017.

Results: Psychodermatologic manifestations are classified as psychophysiologic, primary psychiatric and secondary psychiatric. Their approach requires an evaluation of the skin symptoms and the social, family and occupational issues underlying the problem. Once a diagnosis has been established, both psychiatric and dermatological symptoms need to be addressed. Therapeutic options may include psychotropic drugs, stress management therapies and psychiatrist referral for the former, and supportive dermatologic care and dermatologist referral for the latter. The primary care setting is thus an ideal place to manage and/or refer these conditions, and the Family Doctor’s support may enhance the acceptance of psychiatric treatment and consultations.
Conclusion: The awareness to psychodermatologic manifestations is fundamental, not only because they allow the diagnosis and treatment of an underlying psychiatric problem, but also because these skin disorders can worsen them through depression, humiliation, frustration, social phobia, negative impact on self-esteem and body image. Being in the first line of care, Family Doctors, with their holistic approach, are the ones best positioned to help these patients.