Managing children with daytime urinary incontinence: a survey of Dutch general practitioners

BACKGROUND

In the Netherlands, parents of children with daytime urinary incontinence (UI) first consult general practitioners (GPs). However, GPs need more specific guidelines for daytime UI management, resulting in care and referral decisions being made without clear guidance.

OBJECTIVES

We aimed to identify Dutch GP considerations when treating and referring a child with daytime UI.

METHODS

We invited GPs who referred at least one child aged 4-18 years with daytime UI to secondary care. They were asked to complete a questionnaire about the referred child and the management of daytime UI in general.

RESULTS

Of 244 distributed questionnaires, 118 (48.4%) were returned by 94 GPs. Most reported taking a history and performing basic diagnostic tests like urine tests (61.0%) and physical examinations (49.2%) before referral. Treatment mostly involved lifestyle advice, with only 17.8% starting medication. Referrals were usually at the explicit wish of the child/parent (44.9%) or because of symptom persistence despite treatment (39.0%). GPs usually referred children to a paediatrician (n = 99, 83.9%), only referring to a urologist in specific situations. Almost half (41.4%) of the GPs did not feel competent to treat children with daytime UI and more than half (55.7%) wanted a clinical practice guideline. In the discussion, we explore the generalisability of our findings to other countries.

CONCLUSION

GPs usually refer children with daytime UI to a paediatrician after a basic diagnostic assessment, usually without offering treatment. Parental or child demand is the primary stimulus for referral.

Sex and income inequalities in preventive services in diabetes

BACKGROUND

Cancer preventive services (gynaecological cancer screening, colon cancer screening) and cardiometabolic screening are recommended by guidelines to individuals. People with diabetes were less likely to receive them than those without diabetes in some studies.

OBJECTIVES

To analyse differences in the coverage of preventive services in people with diabetes compared to non-diabetic individuals and in people with diabetes according to sex and household income.

METHODS

We analysed data collected from the European Health Interview Survey 2013-2015, including individuals aged 40-74 (n = 179,318), 15,172 with diabetes from 29 countries. The income of a household (HHI) was described in quintiles. The relationship between the coverage of preventive services (cardiometabolic, vaccination, cancer screening) and sociodemographic characteristics was analysed with multiple logistic regression.

RESULTS

Women comprised 53.8% of the total and 40% were 60-74 years. People with diabetes compared to those without diabetes had higher reported coverage of cardiometabolic screening (98.4% vs. 90.0% in cholesterol measurement; 97.0% vs. 93.6% in blood pressure measurement), colorectal cancer screening (27.1% vs. 24.6%) but lower coverage of gynaecological cancer screening (mammography: 29.2% vs. 33.5%, pap smear test: 28.3% vs. 37.9%). Among diabetic patients, women were less likely to receive cholesterol screening (OR = 0.81; 95% CI: 0.72-0.91) and colon cancer screening (OR = 0.79; 95% CI: 0.73-0.86) compared to men. Being affluent was positively associated with receiving cardiometabolic screening and mammography in diabetic patients.

CONCLUSION

People with diabetes reported higher coverage of preventive services except gynaecological cancer screening. Disparities were found in diabetes among women and less affluent individuals.

The experiences and thoughts of Turkish family physicians about COVID-19 pandemic: A qualitative study

BACKGROUND

Efforts to contain the SARS-CoV-2 virus would fall short without strong primary health care.

OBJECTIVES

In this study, we aimed to determine the experiences, views and suggestions of family physicians regarding their roles, primary care health systems' preparedness and the challenges/needs for a better organisation during the pandemic via in-depth exploration.

METHODS

Twenty-one family physicians working in different cities of Turkey participated in semi-structured interviews between 15/08/2020-21/01/2021. Convenience sampling was used. We did this qualitative study through interviews by telephone. Participants were asked seven open-ended questions. Thematic analysis was used, which included reading the transcript, identifying significant phrases and formulating meanings and validating meanings through research team discussions to reach consensus, identifying themes.

RESULTS

Ten of the participants were female and the average age of the participants was 39.5 (SD = 10.5) years. Twelve of the family physicians are specialists in family medicine. Four themes were identified: role of primary care in the pandemic, pandemic preparedness of primary care, challenges of working in primary care centres during the COVID-19 pandemics, and approaches to future pandemics.

CONCLUSION

Our study showed that, despite unprepared primary care and undefined roles of family physicians in pandemic planning, family physicians played a significant role in pandemic management.

Learning objectives of Belgian general practitioner trainees regarding their hospital training: A qualitative study

Background

In Europe, hospital training is integrated in the postgraduate curriculum of General Practitioners (GPs) according to the European Directives. However, little is known about the specific learning objectives of GP trainees during this training.

Objectives

This exploratory study investigated GP trainees’ expected learning objectives for their hospital training and the factors influencing the learning process.

Methods

Semi-structured interviews were conducted in three focus groups consisting of first-year GP trainees before their hospital training. Data were coded thematically and analysed in NVivo.

Results

A total of 22 Belgian GP trainees (55% females, average age of 26.2 years) were interviewed. Three major themes emerged: learning objectives, factors influencing learning and organisational aspects. GP trainees mainly wanted to improve their knowledge of common conditions by conducting consultations and follow certain patients’ hospitalisation trajectory. Emergency medicine or internal medicine was the preferred specialty. Other GP trainees wanted to learn more about some specific conditions. Conversely, an overloaded work schedule was dreaded to hinder effective learning. Regular meetings and supervision from their hospital trainer were deemed crucial to strengthen GP trainees’ learning trajectory.

Conclusion

GP trainees wanted to learn more about both common conditions and some specific conditions. Their previous year in a GP setting strengthened their confidence and facilitated purposeful learning. Relieving GP trainees from administrative tasks when working as supplementary doctors could strike a better balance between the continuity of the clinical department and their personal learning objectives.

Frequency and management of emergencies in primary care offices: A cross-sectional study in northwestern Germany

BACKGROUND

Little literature exists on emergencies within primary care offices.

OBJECTIVES

We aimed to study the occurrence of emergencies and confidence in dealing with them among primary care physicians (PCPs) in Germany.

METHODS

We conducted a cross-sectional study among all PCPs with licences to practice with an own office (n = 915) in a northwestern region in Germany in 2019. Participants were asked to estimate the frequency and type of emergencies that occurred in the last 12 months in their office and about their confidence in managing emergency situations.

RESULTS

Answers from 375 PCPs could be analysed (response: 41.0%); 95.7% reported at least one emergency in their office within the last 12 months (mean 12.9). PCPs from rural offices reported more emergencies (on average 13.7 vs. 9.6). Acute coronary syndrome, cardiac arrhythmia and dyspnoea were the most common emergencies. A greater likelihood of feeling more confident in managing medical emergencies was found among male physicians, general internists, PCPs additionally qualified as emergency physicians and those with previous training in the emergency department and intensive care unit. In contrast, more general practitioners felt secure treating paediatric emergencies than general internists (highest level of confidence 22.1% vs. 16.3%).

CONCLUSION

In Germany, emergencies in primary care offices occur on average once a month and more often in rural than urban areas. While most PCPs are confident in managing medical emergencies, some differences related to the training path became apparent. Ongoing training programmes may be tailored to improve emergency skills.

Management and Outcomes of Adults Diagnosed with Acute Pulmonary Embolism in Primary Care: Community-Based Retrospective Cohort Study

BACKGROUND

The management and outcomes of patients diagnosed with acute pulmonary embolism in primary care have not been characterized.

OBJECTIVE

To describe 30-day outcomes stratified by initial site-of-care decisions DESIGN: Multicenter retrospective cohort study PARTICIPANTS: Adults diagnosed with acute pulmonary embolism in primary care in a large, diverse community-based US health system (2013-2019) MAIN MEASURES: The primary outcome was a composite of 30-day serious adverse events (recurrent venous thromboembolism, major bleeding, and all-cause mortality). The secondary outcome was 7-day pulmonary embolism-related hospitalization, either initial or delayed.

KEY RESULTS

Among 652 patient encounters (from 646 patients), median age was 64 years; 51.5% were male and 70.7% identified as non-Hispanic white. Overall, 134 cases (20.6%) were sent home from primary care and 518 cases (79.4%) were initially referred to the emergency department (ED) or hospital. Among the referred, 196 (37.8%) were discharged home from the ED without events. Eight patients (1.2%; 95% CI 0.5-2.4%) experienced a 30-day serious adverse event: 4 venous thromboemboli (0.6%), 1 major bleed (0.2%), and 3 deaths (0.5%). Seven of these patients were initially hospitalized, and 1 had been sent home from primary care. All 3 deaths occurred in patients with known metastatic cancer initially referred to the ED, hospitalized, then enrolled in hospice following discharge. Overall, 328 patients (50.3%) were hospitalized within 7 days: 322 at the time of the index diagnosis and 6 following initial outpatient management (4 clinic-only and 2 clinic-plus-ED patients).

CONCLUSIONS

Patients diagnosed with acute pulmonary embolism in this primary care setting uncommonly experienced 30-day adverse events, regardless of initial site-of-care decisions. Over 20% were managed comprehensively by primary care. Delayed 7-day pulmonary embolism-related hospitalization was rare among the 51% treated as outpatients. Primary care management of acute pulmonary embolism appears to be safe and could have implications for cost-effectiveness and patient care experience.

The EGPRN Research Strategy for general practice in Europe

The European General Practice Research Network (EGPRN) has recently published an updated research strategy with the overall aim being to promote relevant research of the highest quality within general practice/family medicine (GP/FM). The Research Strategy indicates a global direction and serves as a basis for more detailed plans in individual countries that will take into account the characteristics of a country, its specific needs and the level of current research capacity. This paper aims to provide a summary of the EGPRN Research Strategy.The Research Strategy suggests that it is necessary to consider what the knowledge deficits are and to set research priorities. Research capacity building (RCB) is required at all levels. Research in GP/FM will also have to reflect the changes in the profession. An innovative and sustainable-oriented approach to conducting research is needed. Use of existing toolkits and engagement with patient platforms and representative groups are necessary to ensure meaningful user involvement. Knowledge transfer and exchange (KTE) is an important component to ensure a process of exchange between researchers and knowledge users.Working to improve leadership, to support the creation of a research culture in GP/FM and to increase national and international networking are considered as fundamental to ensuring a portfolio of high-quality research and for improving the impact of GP/FM research. The recommendations in the Research Strategy are based on a review of the literature on general practice research from 2010 to 2019 and are set in the context of a theoretical framework.

Integrating general practitioners into crisis management would accelerate the transition from victim to effective professional: Qualitative analyses of a terrorist attack and catastrophic flooding

Background

In 2018, Trèbes, 6,000 inhabitants with nine general practitioners (GPs) in southern France, experienced two tragedies; a terrorist attack in March, in which four people were killed, and a catastrophic flood in October, in which six people died and thousands more were affected.

Objectives

We aimed to obtain a substantive theory for improving crisis management by understanding the personal and professional effects of the two successive disasters on GPs in the same village.

Methods

This qualitative study conducted complete interviews with eight GPs individually, with subsequent analyses involving the conceptualisation of categories based on grounded theory.

Results

The analysis revealed that GPs underwent a double status transition. First, doctors who experienced the same emotional shock as the population became victims; their usual professional relationship changed from empathy to sympathy. The helplessness they felt was amplified by the lack of demand from the state to participate in the first emergency measures; consequently, they lost their professional status. In a second phase, GPs regained their values and skills and acquired new ones, thus regaining their status as competent professionals. In this context, the participants proposed integrating a coordinated crisis management system and the systematic development of peer support.

Conclusion

We obtained valuable information on the stages of trauma experienced by GPs, allowing a better understanding of the effects on personal/professional status. Thus, the inclusion of GPs in adaptive crisis management plans would limit the effects of traumatic dissociation while increasing their professional effectiveness.

Family history tools for primary care: A systematic review

Background

Many medical family history (FH) tools are available for various settings. Although FH tools can be a powerful health screening tool in primary care (PC), they are currently underused.

Objectives

This review explores the FH tools currently available for PC and evaluates their clinical performance.

Methods

Five databases were systematically searched until May 2021. Identified tools were evaluated on the following criteria: time-to-complete, integration with electronic health record (EMR) systems, patient administration, risk-assessment ability, evidence-based management recommendations, analytical and clinical validity and clinical utility.

Results

We identified 26 PC FH tools. Analytical and clinical validity was poorly reported and agreement between FH and gold standard was commonly inadequately reported and assessed. Sensitivity was acceptable; specificity was found in half of the reviewed tools to be poor. Most reviewed tools showed a capacity to successfully identify individuals with increased risk of disease (6.2–84.6% of high and/or moderate or increased risk individuals).

Conclusion

Despite the potential of FH tools to improve risk stratification of patients in PC, clinical performance of current tools remains limited as well as their integration in EMR systems. Twenty-one FH tools are designed to be self-administered by patients.

Distress and Wellbeing among General Practitioners in 33 Countries during COVID-19: Results from the Cross-Sectional PRICOV-19 Study to Inform Health System Interventions

Emerging literature is highlighting the huge toll of the COVID-19 pandemic on frontline health workers. However, prior to the crisis, the wellbeing of this group was already of concern. The aim of this paper is to describe the frequency of distress and wellbeing, measured by the expanded 9-item Mayo Clinic Wellbeing Index (eWBI), among general practitioners/family physicians during the COVID-19 pandemic and to identify levers to mitigate the risk of distress. Data were collected by means of an online self-reported questionnaire among GP practices. Statistical analysis was performed using SPSS software using Version 7 of the database, which consisted of the cleaned data of 33 countries available as of 3 November 2021. Data from 3711 respondents were included. eWBI scores ranged from -2 to 9, with a median of 3. Using a cutoff of ≥2, 64.5% of respondents were considered at risk of distress. GPs with less experience, in smaller practices, and with more vulnerable patient populations were at a higher risk of distress. Significant differences in wellbeing scores were noted between countries. Collaboration from other practices and perception of having adequate governmental support were significant protective factors for distress. It is necessary to address practice- and system-level organizational factors in order to enhance wellbeing and support primary care physicians.

Primary Evans syndrome in an adult man

Evans syndrome (ES) is a simultaneous or subsequent development of two haematological disorders, autoimmune haemolytic anaemia (AIHA) and immune thrombocytopenia (ITP). It can be primary (idiopathic) or secondary (associated with an underlying disease). Primary Evans is a diagnosis of exclusion and has a poorer prognosis than AIHA or ITP alone. We present a 55-year-old man who presented with weakness and lethargy and was diagnosed to be suffering from primary ES.

Implementation of Primary Palliative Care in five Belgian regions: A qualitative study on early identification of palliative care needs by general practitioners

Background

To deliver optimal palliative care, a Care Pathway for Primary Palliative Care (CPPPC) was developed. This CPPPC was implemented by general practitioners (GPs) in territories of five Belgian palliative care networks (2014–2016). Belgian doctors have much therapeutic freedom, and do not commonly follow guidelines.

Objectives

To assess how palliative care was provided by GPs before the CPPPC and its implementation project were presented publicly.

Methods

Between 2013 and 2015, seven focus groups with GPs were conducted. Participants included 15 GPs in three French-speaking focus groups and 26 GPs in four Dutch-speaking focus groups, with diversity for age, gender, palliative care experience and practice context. Some GPs implemented the CPPPC later.

Results

GPs considered each palliative care case unique and disliked strict protocols. However, they expressed a need for peer review and reflective frameworks. GPs felt it is important to identify palliative care patients ‘timely’, but found this difficult. Screening methods help, but are not widely used. GPs struggled most with identifying palliative care needs in non-oncological patients. Bad news breaking was considered difficult. Continuity of care was considered very important. However, advance care planning seemed more widely practised by Dutch-speaking GPs than by French-speaking GPs. The taboo of palliative care provoked emotional discussions.

Conclusion

Palliative care frameworks which help GPs to deliver ‘tailor-made’ care have more chance to be adopted than strict protocols. GPs should be given education for bad news breaking. Palliative care and advance care planning practices differ locally: guideline dissemination plans should respect these local differences.

Primary presentation of sarcoidosis with profound bilateral sensorineural hearing loss

We present a case of a 7-year-old Afro-Caribbean girl presenting with rapidly progressive bilateral sensorineural hearing loss. She was found to have an elevated Angiotensin converting enzyme (ACE) and mediastinal lymphadenopathy containing non-caseating granulomas with multinucleate giant cells, in keeping with sarcoidosis. Cranial imaging demonstrated labyrinthitis. She underwent urgent bilateral cochlear implantation with rehabilitation of hearing sufficient to restart education within 1 month.

Predictors for mortality due to acute exacerbation of COPD in primary care: Derivation of a clinical prediction rule in a multicentre cohort study

Background

In primary care (PC), 80% of the acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are treated. However, no predictive model has been derived or validated for use in PC to help general practitioners make decisions about these patients.

Objectives

To derive a clinical prediction rule for mortality from any cause 30 days after the last PC visit.

Methods

Between December 2013 and November 2014, we performed a cohort study with people aged 40 and over who were treated for AECOPD in 148 health centres in Spain. We recorded demographic variables, past medical history, signs, and symptoms of the patients and derived a logistic regression model.

Results

In the analysis, 1,696 cases of AECOPD were included and 17 patients (1%) died during follow-up. A clinical prediction rule was derived based on the exacerbations suffered in the last 12 months, age, and heart rate, displaying an area under the receiver operating characteristic curve of 0.792 (95% confidence interval, 0.692–0.891) and good calibration.

Conclusion

This rule stratifies patients into three categories of risk and suggests to the physician a different action for each category: managing low-risk patients in PC, referring high-risk patients to hospitals and taking other criteria into account for decision-making in patients with moderate risk. These findings suggest that it is possible to accurately estimate the risk of death due to AECOPD without complex devices. Future studies on external validation and impact assessment are needed before this prediction rule may be used in clinical practice.

COVID-19's impact on primary care and related mitigation strategies: A scoping review

Background

The COVID-19 pandemic has had a substantial impact on primary care throughout Europe and globally.

Objectives

This review aims to ascertain how the pandemic has impacted primary care service provision/patients and to examine strategies to mitigate these impacts.

Methods

The scoping review framework comprised a six-stage process developed by Arksey and O'Malley. The search process was guided by the Joanna Briggs Institute three-step search strategy and involved searching the PubMed, Embase, Scopus, CINAHL Plus, and Cochrane Library databases. The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. A thematic analysis approach by Braun and Clarke was used to interpret the findings.

Results

Thirty-two studies from 18 countries and six continents were included, 13 reported original research, three were reviews, and 16 were case reports reporting healthcare systems’ experiences of dealing with the pandemic. Emerging themes concerned the COVID-19 pandemic’s impact on primary care service provision and patients, the impact of the rapid transition to telemedicine due to COVID-19 on primary care, and strategies to mitigate the impact of COVID-19 on primary care (i.e. infection prevention and control measures, alternatives/modifications to traditional service delivery or workflow, government policy responses, and education).

Conclusion

The COVID-19 pandemic has considerably impacted on primary care at both service and patient levels, and various strategies to mitigate these impacts have been described. Future research examining the pandemic’s ongoing impacts on primary care, as well as strategies to mitigate these impacts, is a priority.

Communication between Dutch community nurses and general practitioners lacks structure: An explorative mixed methods study

Background

Community nurses and general practitioners evaluate their patient-related communication to be poor. However, their actual communication has hardly been investigated and specific strategies for improvement are unclear.

Objectives

To explore actual community nurse-general practitioner communication in primary care and gain insights into communication style, and conversation structure and their determinants.

Methods

A mixed-methods design was applied. Telephone conversations between community nurses and general practitioners in the Netherlands were recorded and transcribed verbatim. We measured structure and the duration of their conversations, and community nurses’ self-confidence towards general practitioners and their trust in and familiarity with the conversation partner. A thematic analysis was applied to the transcripts of the conversations. Correlations between these determinants were calculated using Spearman’s correlation coefficient.

Results

The 18 community nurses recorded 23 conversations with general practitioners. Qualitative analysis revealed that many conversations lacked structure and conciseness, i.e. the nurses started conversations without a clearly articulated question and did not provide adequate background information. The mean duration of their conversations with doctors was 8.8 min. Community nurses with higher self-confidence towards doctors communicated in a more structured way (p = 0.01) and general practitioners were more satisfied about the conversations (p = 0.01).

Conclusion

This exploratory study of actual community nurse-doctor telephone conversations in primary care identified communication structure and nurse self-confidence towards general practitioners as key targets for the improvement of interprofessional communication, which may increase the effectiveness of community nurse-general practitioner collaboration.

Resilience in family caregivers of patients diagnosed with advanced cancer - unravelling the process of bouncing back from difficult experiences, a hermeneutic review

Background

Despite the risk for developing mental disorders, most of advanced cancer patients’ family caregivers undergo a resilient process throughout the caregiving period. Research on resilience in caregivers of advanced cancer patients is scarce and further hindered by the lack of a univocal definition and a theoretical framework.

Objectives

To provide clarity on the concept of resilience by proposing an integrative view that can support health care professionals and researchers in conducting and interpreting research on resilience.

Methods

The review process was inspired by the hermeneutic methodology: a cyclic review process, consisting of repeated searching and analysing until data saturation is reached and focussed on achieving a deeper understanding of ill-defined concepts. The definitions from eighteen reviews on resilience and the theoretical frameworks from eight concept analyses were analysed. The composing elements of resilience were listed and compared.

Results

The American Psychological Association’s definition of resilience and Bonanno’s theoretical framework are suggested to guide further research on resilience. Moreover, four knowledge gaps were uncovered: (1) How do resilience resources interact? (2) What are the key predictors for a resilient trajectory? (3) How do the resilient trajectories evolve across the caregiving period? And (4) how does the patient’s nearing death influence the caregiver’s resilience?

Conclusion

To address flaws in conceptualisation and the resulting gaps in knowledge, we suggest a definition and a theoretical framework that are suited to allow heterogeneity in the field, but enables the development of sound interventions, as well as facilitate the interpretation of intervention effectiveness.

Decades of cough: delayed recognition of atypical cystic fibrosis in an adult patient

We present a case of a 30-year-old male diagnosed with atypical cystic fibrosis. This report demonstrates the heterogeneity of the presentation of this common genetic disease.

Varicella-zoster meningitis in an immunocompetent young man presenting with a painless erythematous rash

A 32-year-old man presented with a 7-day history of generalised headache, intermittent fever, emesis and diarrhoea. Four days after symptom onset, he developed a vesicular rash on his medial left thigh, without associated pain, paraesthesia or pruritus. He had no significant past medical history, and no HIV risk factors. He was presumed to have enteroviral meningitis and was commenced on supportive therapy. Lumbar puncture was performed and cerebrospinal fluid (CSF) analysis revealed a lymphocytic pleocytosis. While awaiting CSF serology, the formation of a new vesicle was noted at the site of the rash and was swabbed. Results for both the CSF and vesicle swab returned positive for varicella-zoster virus (VZV) confirming concurrent VZV meningitis with atypical painless herpes zoster in a young immunocompetent patient. He was initiated on intravenous acyclovir and made a full recovery after 2 weeks of treatment.

Low-dose naltrexone as a treatment for chronic fatigue syndrome

Naltrexone is used as an off-label treatment in low doses for several chronic immune-modulated disorders in many countries. Although only small-scale clinical trials have been performed, these suggest efficacy in several diseases including Crohn's disease, fibromyalgia and Gulf War Illness. Despite numerous internet reports of response to low-dose naltrexone (LDN), no clinical trials exist in people with chronic fatigue syndrome. This condition is characterised by chronic profound fatigue, postexertional malaise, pain and autonomic and neurocognitive disturbances. This series of three case reports compiled by people with long-term ill-health due to chronic fatigue syndrome shows the range of responses they observed when taking LDN, from life changing to a reduction in some symptoms only. Treatment doses ranged from 4 to 12 mg. Clinical trials may be warranted to explore the potential use of naltrexone in people with these debilitating illnesses which currently have no licensed treatments available.

Association of Mondor's disease with oral contraceptive pills

Mondor's disease (MD) is a rare disease characterised by thrombophlebitis of superficial veins in the body. We describe a case of a 28-year-old woman with a painful cord-like lesion of the right breast (3 cm) overlying the right upper quadrant. The patient was recently prescribed metformin and oral contraceptive pills for symptomatic polycystic ovarian syndrome. Right breast ultrasound showed a tubular anechoic structure with several areas of narrowing, resembling a beaded appearance. The patient was diagnosed with MD associated with use of oral contraceptive pills. We recommended the patient to discontinue oral contraceptive because discontinuation of the causative drug is important. The patient was started on topical non-steroidal anti-inflammatory drugs and a therapeutic dose of enoxaparin. The patient showed significant clinical improvement after 5 days. At 6-week outpatient follow-up, complete resolution of the disease was noted.

Acute transient psychotic disorder precipitated by Brexit vote

A man in his 40s was brought to the accident and emergency department in an acute psychotic state, 3 weeks after the European Union referendum results in the UK were declared. His mental health had deteriorated rapidly following the announcement of the results, with significant concerns about Brexit. He presented as agitated, confused and thought disordered. He had auditory hallucinations, and paranoid, referential, misidentification and bizarre delusions. He recovered completely within 2 weeks after a brief admission and treatment with olanzapine. He had experienced a similar episode of much less severity 13 years previously after major work related stress which resolved completely within a few days. He was experiencing stress related to work and family prior to the current episode which could potentially have been a contributory factor. Political events can act as major psychological stressors and have a significant impact on the mental health of people, especially those with a predisposition to develop mental illness.

A fatal case of levamisole induced bone marrow failure

A 20-year-old college student presented with high grade, intermittent fever for 10 days associated with blood stained loose stools after taking tablet levamisole for 17 days for vitiligo vulgaris. He was febrile, had a toxic appearance and appeared pale. Investigations showed neutropaenia with thrombocytopaenia. Blood cultures were sterile and stool cultures did not grow any enteric pathogens. His bone marrow examination was suggestive of an aplastic anaemia. He was administered empirical antibiotics, granulocyte colony stimulating factor and platelet transfusions. However, his fever and blood stained stools persisted. A repeat bone marrow examination after 2 weeks still revealed a hypoplastic marrow. Hence, a diagnosis of a levamisole induced bone marrow failure was made. While being worked up for an allogeneic stem cell transplantation, he developed neutropaenic enterocolitis and refractory septic shock with carbapenem resistant Klebsiella pneumoniae and succumbed to his illness.

Chronic migraine headache and multiple dental pathologies causing cranial pain for 35 years: the neurodental nexus

We report a case that illustrates how chronic migraine headaches and multiple dental pathologies caused severe and long-standing cranial pain that affected the quality of life of a man for more than 35 years. His case was investigated at several settings including the neurology outpatient clinic of the hospital without a definitive diagnosis or resolution. After investigations, multiple oral pathologies including two occult dental abscesses were diagnosed. Once both affected teeth and associated abscesses were surgically removed, with subsequent antibiotic therapy the headaches resolved.

Diagnosis of hypothenar hammer syndrome in a patient with acute ulnar artery occlusion

A 56-year-old truck driver with a history of tobacco use presented with acute onset digital ischaemia in the ulnar distribution of his dominant hand, associated with severe pain. Occupational exposures included extensive manual labour and prolonged vibratory stimuli. Workup with Doppler and angiography confirmed the diagnosis of hypothenar hammer syndrome (HHS). After the failure of medical management, he underwent ulnar artery thrombectomy with reconstruction and arterial bypass grafting. His pain improved significantly postsurgically, and he was able to return to a normal routine. This case illustrates the classic presentation, examination, imaging findings and management options of HHS. HHS should be considered in patients with digital ischaemia and associated occupational exposures. Diagnosing the condition appropriately allows for optimal management, aiming at minimising symptoms and maximising quality of life.

Thymoma associated paraneoplastic encephalitis (TAPE), a potential cause of limbic encephalitis

A 59-year-old man presents with expressive aphasia and short term memory deficits. Shortly thereafter, he started developing staring spells and intermittent right hand spasms, preliminarily thought to be simple partial seizures. Subsequent MRI brain imaging was highly suggestive of herpes simplex virus (HSV) encephalitis; however, HSV PCR from cerebrospinal fluid was negative. On further testing, the patient was found to have an autoimmune encephalitis thought to be related to an incidentally found thymoma. His clinical presentation, in conjunction with imaging and response to therapy, was strongly suggestive of thymoma associated paraneoplastic encephalitis. Early recognition is the only way to ensure prompt initiation of appropriate treatment. Immunotherapy and cancer directed therapy (including tumour resection, if indicated) have been shown to have favourable outcomes, improved speed of neurological recovery and reduced risk of relapses. Without treatment, progressive neurologic deterioration can occur over months to years, eventually resulting in death.

Type II polyglandular autoimmune syndrome: a case of Addison's disease precipitated by use of levothyroxine

A 46-year-old woman was referred to the endocrinology clinic for evaluation of progressive fatigue, dizziness and treatment-resistant hypothyroidism. Initial laboratory results revealed hypothyroidism, hyponatraemia and hyperkalaemia. Liothyronine sodium (Cytomel) was initiated, which exacerbated her fatigue and dizziness. Suspecting adrenal insufficiency, an 08:00 cortisol level was obtained and found to be low with failure to increase following cosyntropin stimulation test. Diagnosis of primary adrenal insufficiency was confirmed via CT abdomen and pelvis revealing diminutive adrenal glands and elevated 21-hydroxylase antibody. Treatment was initiated with hydrocortisone 10 mg every morning and 5 mg at 16:00/day, with plan for patient follow-up in 3 weeks to assess need for mineralocorticoid replacement. Polyglandular syndromes are rare and have a wide variety of presentation. Thus, we recommend screening patients with a single autoimmune disorder who do not respond to conventional therapy to prevent possible life-threatening adrenal crisis.

Poor or fair self-rated health is associated with depressive symptoms and impaired perceived physical health: A cross-sectional study in a primary care population at risk for type 2 diabetes and cardiovascular disease

Background: Psychosocial factors such as depressive symptoms should be considered when assessing cardiovascular (CV) risk. Depressive symptoms are suggested to be associated with poor perception of one's health, i.e. self-rated health (SRH). Thus, assessing SRH could be a practical tool in CV risk prediction. However, SRH may also emphasize physical, mental or social aspects. Objectives: To assess the relationship of SRH and depressive symptoms, classic CV risk factors and perceived physical health among persons at risk for type 2 diabetes (T2D) and cardiovascular disease (CVD). Methods: In this cross-sectional study in a primary care population, 2555 persons (mean age 58 ± 7, 56% women) at risk for T2D or CVD were evaluated. Generalized linear statistical models were used to evaluate the association of depressive symptoms (Beck's Depression Inventory score ≥10), CV risk factors, and perception of SRH and physical health (assessed by Short Form Health Survey). Results: Poor or fair health was reported by 40% of the participants. They had more unhealthy lifestyle habits and CV risk factors than subjects rating their health as at least good. Among those with poor or fair SRH, the prevalence of depressive symptoms was 36% and associated with perception of physical health. Conclusion: Poor SRH is associated with depressive symptoms and impaired perceived physical health. Assessing SRH might be useful for detecting possible depressive symptoms in patients in CV risk management and diabetes care.

Recurrent unilateral cellulitis: is it May-Thurner syndrome (MTS)?

May-Thurner syndrome (MTS) is a differential diagnosis to be considered in a patient with recurrent unilateral cellulitis. A 73-year-old woman initially presented with recurrent unilateral cellulitis of her left lower limb. A CT scan demonstrated a stenosed left common iliac vein (CIV) narrowed at its origin by the proximal right common iliac artery consistent with MTS. The chronicity of the condition at the time of diagnosis made attempts to recanalise the CIV unsuccessful. A diagnosis of MTS should be considered in a patient with chronic unilateral limb oedema/cellulitis as it represents a potentially treatable condition if detected early.

Pustules on the back possibly triggering toxic-shock syndrome

We herein describe an irregular case of toxic-shock syndrome (TSS). A previously healthy 28-year-old Japanese man developed a sudden-onset high fever. The patient was suffering from conjunctival hyperaemia, gastrointestinal symptoms such as vomiting and diarrhoea, and systemically diffused macular erythroderma. Further physical examination detected pustules on his back, which self-destructed over time. Laboratory revealed multiple organ failures. Subsequently, scalded skin on the face and desquamation in the limb extremities emerged by day 10, leading to the diagnosis of TSS, despite his stable circulatory dynamics through the course. Learning points for clinicians include that they should recall TSS as a possible disease concurrently causing high fever, systemic rash and multiple organ dysfunctions, even without being in a state of shock. The characteristic desquamations emerged in the limb extremities after hospitalisation were of help in diagnosing TSS.

Cutaneous leprosy in Central Florida man with significant armadillo exposure

Leprosy is a chronic infectious, granulomatous disease caused by the intracellular bacillus Mycobacterium leprae that infects macrophages and Schwann cells. While relatively rare in the USA, there is about 200 new cases of leprosy every year with the majority occurring in the southern parts of the country. It is believed to be linked to the region of the nine-banned armadillo in patients with no significant travel history outside of the country. In this case report, we encountered a 58-year-old Central Florida man that had extensive exposure to armadillos and presented with the typical symptoms of large erythaematous patches, numbness and peripheral nerve hypertrophy. Once diagnosed properly, patients are then reported to the National Hansen's Centre who provides the multidrug therapy for 12-24 months. Due to its rarity and its ability to mimic other more common ailments, leprosy should be included in the differential diagnosis in patients that have significant exposure to armadillos, live in the southern part of the country or have recently travelled to countries that have a high prevalence of leprosy.

Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia (DIPNECH) with liver metastases

Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia (DIPNECH) is a rare pulmonary disorder characterised by classic radiological findings and symptoms of obstructive lung disease. DIPNECH is considered a precursor to carcinoid tumours in the lungs. In this case, we describe a patient with years of unexplained dry cough presenting with 2 weeks of progressive nausea and vomiting, and found to have massive hepatomegaly on examination. By CT-PE, she was diagnosed with DIPNECH, and abdominal MRI revealed metastatic carcinoid tumours. Despite its non-specific presentation, DIPNECH has characteristic radiological findings of mosaic attenuation with numerous pulmonary nodules. DIPNECH requires early identification and close surveillance to prevent progression to carcinoid tumours. Thus, it is critical for frontline providers to consider this diagnosis as part of their differential when other common causes of obstructive lung disease have been ruled out.

Physician's role in prescribing opioids in developing countries

In developed countries, addressing the growing opioid addiction epidemic is focused on preventive measures, developing better overdose-reversal medications and designing newer strategies to treat addiction. Primary prescribers of the therapeutic use of opioids might play a definite role in the aetiology of the epidemics. Developing countries could be affected by similar issues; however, given that no updated statistics are available, it is possible that their populations undergo problems similar to those for which current data is available. Concerns have arisen regarding synthetic opioid tramadol which, given its fast and potent analgesic effects, low cost and easy availability is widely prescribed. A debate remains as to whether tramadol induces addictive effects like those of stronger analogues such as oxycodone or fentanyl. Here we present a case of tramadol dependence in an Ecuadorian patient and find that substance abuse can occur in normal individuals affected by chronic pain, otherwise treatable with standard methods.

Epistaxis and gross haematuria with severe thrombocytopaenia associated with influenza vaccination

Epistaxis may be attributed to many causes during the winter including dry mucous membranes from low indoor humidity from heating. However, epistaxis may also be due to thrombocytopaenia. Immune thrombocytopaenia purpura (ITP) is an autoimmune disorder causing thrombocytopaenia. Viral infections sometimes lead to ITP. Vaccines, predominantly the measles-mumps-rubella vaccine, have been associated with the development of ITP. There are several published case reports regarding influenza vaccine induced ITP. However, an association between ITP and influenza vaccination has not been firmly proven yet. We report the case of an adult with three episodes of epistaxis, each within 1 week of receiving a yearly influenza trivalent inactivated vaccine, the last episode being more severe and also featuring gross haematuria.

Not 'just' a foreign body in the ear canal

Foreign bodies are commonly seen by the Ear, Nose and Throat emergency team with cotton wool being the most common aural foreign body seen in the adult population. Most complications secondary to aural foreign bodies described in the literature are minor and rarely require any surgical intervention. Here, we present two cases with impacted cotton wool as aural foreign bodies which resulted in suppurative labyrinthitis and osteomyelitis causing profound sensorineural hearing. These cases highlight the importance of considering aural foreign bodies in the differential diagnosis in those presenting with unilateral symptoms as significant complications, although rare, can occur, particularly in those with delayed diagnosis.

Post-total knee arthroplasty herpes zoster activation

Herpes zoster is a clinical manifestation of reactivation of varicella-zoster virus (VZV) that lies dormant in the dorsal root ganglia after a past primary infection. It can be associated with severe pain, a crop of vesicles in typical dermatomal distribution but the neuralgic pain persists long, making the patient uncomfortable and often disturbing patient's sleep. There are cases reported after trauma or post surgeries that are mainly related to organ transplant or malignancy. In the literature, there is a solitary report of VZV infection along the sciatic nerve post ipsilateral hip and contralateral knee joint replacement. Here, we report a VZV infection in post knee replacement setting along the L2-3 dermatomal distribution.

Integrating a nationally scaled workforce of community health workers in primary care: a modelling study

OBJECTIVE

To model cost and benefit of a national community health worker workforce.

DESIGN

Modelling exercise based on all general practices in England.

SETTING

United Kingdom National Health Service Primary Care.

PARTICIPANTS

Not applicable.

DATA SOURCES

Publicly available data on general practice demographics, population density, household size, salary scales and screening and immunisation uptake.

MAIN OUTCOME MEASURES

We estimated numbers of community health workers needed, anticipated workload and likely benefits to patients.

RESULTS

Conservative modelling suggests that 110,585 community health workers would be needed to cover the general practice registered population in England, costing £2.22bn annually. Assuming community health workerss could engage with and successfully refer 20% of eligible unscreened or unimmunised individuals, an additional 753,592 cervical cancer screenings, 365,166 breast cancer screenings and 482,924 bowel cancer screenings could be expected within respective review periods. A total of 16,398 additional children annually could receive their MMR1 at 12 months and 24,716 their MMR2 at five years of age. Community health workerss would also provide home-based health promotion and lifestyle support to patients with chronic disease.

CONCLUSION

A scaled community health worker workforce integrated into primary care may be a valuable policy alternative. Pilot studies are required to establish feasibility and impact in NHS primary care.

Rare clinical manifestation of community-acquired pneumonia

A 71-year-old patient was admitted due to fever and persistent (>48 hours) hiccups. History and physical examination were not instructive. Lab tests were not specific, showing an inflammatory response. Chest film did not demonstrate opacities. The patient was treated with chlorpromazine with no relief. Fever and hiccups persisted, and therefore neck and chest CT was performed revealing a right lower lobe infiltrate, a finding consistent with pneumonia. Antibiotics were initiated and within 48 hours fever and hiccups resolved and patient recovered. Although hiccups are rarely described as a clinical manifestation of community acquired pneumonia, one should consider this diagnosis in a patient with unexplained fever.

Developments in euthanasia practice in the Netherlands: Balancing professional responsibility and the patient's autonomy

In 2015, euthanasia accounted for 4.5% of deaths in the Netherlands, of which 93% were performed by a GP. Historically, a conflict of physician’s duties—to alleviate unbearable suffering and at the same time preserve the patient’s life—is central to the justification of euthanasia practice in the Netherlands. However, there seems to be a shift towards a greater emphasis on the patient’s autonomous wish as the primary basis for euthanasia. This shift has consequences for the role and interpretation of the physician’s duties in end-of-life care. This paper aims to describe these developments in euthanasia practice and end-of-life decision-making. We describe important relevant developments and look into the role and the meaning of two dimensions of the concept of ‘patient autonomy’ regarding end-of-life decisions, in particular, the euthanasia request. We claim that the concept of autonomy ‘as a right,’ which can be distinguished from autonomy ‘as an ideal,’ narrows the physician’s window of opportunity to offer end-of-life care other than euthanasia.

More counselling for end-of-life decisions by GPs with own advance directives: A postal survey among German general practitioners

BACKGROUND

Although general practitioners (GPs) are among the preferred contact persons for discussing end-of-life issues including advance directives (ADs), there is little data on how GPs manage such consultations.

OBJECTIVES

This postal survey asked German GPs about their counselling for end-of-life decisions.

METHODS

In 2015, a two-sided questionnaire was mailed to 959 GPs. GPs were asked for details of their consultations on ADs: frequency, duration, template use, and whether they have own ADs. Statistical analysis evaluated physician characteristics associated with an above-average number of consultations on AD.

RESULTS

The participation rate was 50.3% (n = 482), 70.5% of the GPs were male; the average age was 54 years. GPs had an average of 18 years of professional experience, and 61.4% serve more than 900 patients per three months. Most (96.9%) GPs perform consultations on living wills (LW) and/or powers of attorney (PA), mainly in selected patients (72.3%). More than 20 consultations each on LWs and PAs are performed by 60% and 50% of GPs, respectively. The estimated mean duration of consultations was 21 min for LWs and 16 min for PAs. Predefined templates were used in 72% of the GPs, 50% of GPs had their ADs. A statistical model showed that GPs with ADs and/or a qualification in palliative medicine were more likely to counsel ≥20 patients per year for each document.

CONCLUSION

The study confirmed that nearly all German GPs surveyed provide counselling on ADs. Physicians with ADs counsel more frequently than those without such documents.