Teaching limited compression ultrasound to general practitioners reduces referrals of suspected DVT to a hospital: a retrospective cross-sectional study

Background The aim of this study was to retrospectively determine whether teaching limited compression ultrasound (LCUS) to general practitioners (GP) would reduce the number of patients with a suspected lower extremity DVT referred to a hospital for ultrasound (US) examination. According to the current literature, an LCUS protocol is a safe way to diagnose or exclude lower extremity deep venous thrombosis (DVT) and a good option to radiologist-performed whole-leg ultrasound (US), especially in remote health care units where there may be a limited availability of radiological services. Methods Between 2015 and 2016, altogether 13 GPs working in the same primary care unit were trained in LCUS for DVT diagnostics. The number of annual referrals due to a suspected DVT from Saarikka primary care unit to the closest hospital was evaluated before and after training. The incidence of DVT was considered to be constant. Thus, the reduction of referrals was attributed to the fact that these patients were diagnosed and treated in primary health care. Incidence rate ratio of hospital referrals was calculated. As a measure of safety, all patients diagnosed with a pulmonary embolism in the nearest hospital were evaluated to determine if they had undergone LCUS by a GP in primary care. Results Before training in 2014, there were 60 annual referrals due to a suspected DVT; in 2017, after training, the number was reduced to 16, i.e., a 73.3% decrease. The incidence of referrals decreased from 3.21 to 0.89 per 1000 person-years. (IRR 3.58, 95% CI 2.04–6.66, p < 0.001). No patient with a pulmonary embolism diagnosis had LCUS performed previously, indicating that there were no false negatives, resulting in pulmonary embolism. Conclusions Teaching LCUS to GPs can safely reduce the number of patients with a suspected DVT referred to a hospital substantially.

Usage of herbal medicines among the elderly in a primary care unit in Hat Yai, Songkhla province, Thailand

Background The prevalence of chronic diseases in the elderly is high, and some use herbal medicines instead of, or together with, conventional medicine. Herbal medicine usage may cause adverse events. Objectives To determine the prevalence of herbal medicine usage among the elderly attending a primary care unit (PCU) of Songklanagarind Hospital, a tertiary teaching hospital in Hat Yai, Songkhla province, Thailand, and associated factors, reasons for use, principles considered before use, perceived effects, and history of consultation with medical professionals concerning their herbal medicine usage. Methods We conducted a cross-sectional survey of a convenience sample of elderly patients who visited the PCU. Questionnaires were used to obtain data. Results We included 204 patients who met the eligibility criteria. About two-thirds were women, with a median age of 69.0 years. Most had underlying diseases and were educated. The all time prevalence of herbal medicine usage was 60.8%. Being educated was significantly associated with herbal medicine usage. Among 124 users, 79% did not consider any principles for safe use of herbal medicine, 63% had no knowledge of possible interactions with conventional medicines, and 73% had never been asked about their use of herbal medicines by their health care professionals. Conclusions There is a high prevalence of herbal medicine usage among the elderly Thai patients attending the PCU, especially by the educated. The majority did not consider the principles for safe use of herbal medicine. Health care providers should be more aware of herbal medicine usage and should increase their role in initiating a discussion about herbal medicine usage with elderly patients.

Cost-Effectiveness of Point-of-Care A1C Tests in a Primary Care Setting

Objective: We evaluated the cost-effectiveness of the point-of-care A1c (POC-A1c) test device vs. the traditional laboratory dosage in a primary care setting for people living with type 2 diabetes.Materials and Methods: The Markov model with a 10-year time horizon was based on data from the HealthRise project, in which a group of interventions was implemented to improve diabetes and hypertension control in the primary care network of the urban area of a Brazilian municipality. A POC-A1c device was provided to be used directly in a primary care unit, and for a period of 18 months, 288 patients were included in the point-of-care group, and 1,102 were included in the comparison group. Sensitivity analysis was performed via Monte Carlo simulation and tornado diagram.Results: The results indicated that the POC-A1c device used in the primary care unit was a cost-effective alternative, which improved access to A1c tests and resulted in an increased rate of early control of blood glucose. In the 10-year period, POC-A1c group presented a mean cost of US$10,503.48 per patient and an effectiveness of 0.35 vs. US$9,992.35 and 0.09 for the traditional laboratory test, respectively. The incremental cost was US$511.13 and the incremental effectiveness was 0.26, resulting in an incremental cost-effectiveness ratio of 1,947.10. In Monte Carlo simulation, costs and effectiveness ranged between $9,663.20–$10,683.53 and 0.33–0.37 for POC-A1c test group, and $9,288.28–$10,413.99 and 0.08–0.10 for traditional laboratory test group, at 2.5 and 97.5 percentiles. The costs for nephropathy, retinopathy, and cardiovascular disease and the probability of being hospitalized due to diabetes presented the greatest impact on the model’s result.Conclusion: This study showed that using POC-A1c devices in primary care settings is a cost-effective alternative for monitoring glycated hemoglobin A1c as a marker of blood glucose control in people living with type 2 diabetes. According to our model, the use of POC-A1c device in a healthcare unit increased the early control of type 2 diabetes and, consequently, reduced the costs of diabetes-related outcomes, in comparison with a centralized laboratory test.

The Effect of COVID-19 Pandemic on the Hip Fractures in Advanced Age

Objective: Hip fractures due to domestic low-energy traumas are common problems that can cause significant morbidity and mortality in the elderly population. Since the Covid-19 outbreak, although the lock-down of older people could decrease contagion,the incidence of domestic traumas did not decrease, and led to development of various comorbidities. In this study, we aimed to compare the epidemiology of hip fractures in 6 months of the pandemic in 2020, with the equivalent 6-month period in the previous year to determine the relationship between lock-down and hip fractures due to domestic falls. Method: In this retrospective study, patients over 65 years old who were hospitalized due to hip fractures between May 1st, 2020 - November 30th, 2020 were compared with the similar cohort hospitalized between May 1st, 2019 - November 30th, 2019. The patients were compared in terms of demographic characteristics, American Society of Anesthesiologists (ASA) scores, type of anesthesia, time until surgery, comorbidities, surgical treatment modality, need for postoperative primary care unit, postoperative complications, and mortality. Results: Overall, 210 patients were included in our study. There was no significant difference between the groups regarding demographic characteristics and ASA scores. In the 2020 group, there were eight patients (8.6%) who were Covid-19 PCR- positive. There was no death proven by PCR that was related to COVID-19 disease. Time to surgery, fracture type, anesthesia type did not differ between the two groups. The need for a postoperative primary care unit was higher in the 2020 group. Ninety-day mortality rates were not significantly different between the two groups. Conclusions: In conclusion, despite higher mortality rates described in the literature, there was no Covid -19 associated mortality in our study. Hip fractures in the elderly did not alter with social mobilization; hence they usually occur due to domestic low- energy traumas. Reporting of the information in this patient group by all centers will provide important data in the management of hip fractures in this special process.

Urinary Malondialdehyde as a Biomarker of Type 2 Diabetes Mellitus Treatment in the Primary Care Unit of a Tertiary Care Hospital

Introduction/Objectives The examination of Urinary Malondialdehyde (UMDA) as a biomarker in the involvement of inflammatory response and oxidative stress, as a mechanism underlying the development of diabetes; in addition to complications in followed-up patients at a primary healthcare unit. The level of UMDA and its related factors in T2DM patients, between good and poor glycemic control was investigated. Methods This analytical cross-sectional study was conducted at the primary care unit, of Songklanagarind Hospital; from May 2020 to August 2020. The voluntary patients were divided into 2 groups, by using a percentage of HbA1c ≤7% as a good control T2DM group, and higher than 7% as a poor control T2DM group. The comparison statistics and logistic regression analysis were performed by using R Program. Results A total of 71 patients voluntarily participated in this study, and consisted of: 38 patients with poor glycemic control and 33 patients with good glycemic control. There were no significant differences between the patients; with the exception of smoking habits. The average levels of UMDA of the good control group (2.43 ± 0.91 μg/mL) were slightly lower than the poor control group (2.60 ± 0.96 μg/mL): P-value >.05. Patients who had underlying diseases, smoking, or drinking habits displayed significantly different levels of UMDA. Being a non-smoking patients, and having a higher level of HDL-C with significant protective factors, while having increased level of FBS and triglyceride were pointedly negative factors of oxidative stress status. Conclusion Patients who had good control of T2DM produced better health outcomes than the poor control group. UMDA, FBS, HDL-C, and triglyceride levels could be applied as follow-up criteria in T2DM patients within a primary healthcare setting.

Rates and Factors Associated With Laxative Prescription Among Type 2 Diabetes Patients in Primary Care

Background: Diabetes mellitus (DM) is a common noncommunicable disease. Several gastrointestinal symptoms such as diarrhea, chronic constipation, and fecal incontinence are often observed in DM patients; among these, chronic constipation is the most commonly reported. Given the growing prevalence of diabetes-associated chronic constipation, the problem of laxative prescribed without diagnosis of constipation among type 2 diabetes patients has been found in the primary care unit. Therefore, it should attend to investigate the rate and factors associated with laxative prescription in type 2 diabetes. Objective: To evaluate the rate and factors associated with laxative prescription in type 2 diabetic patients at the primary care unit and general practitioner outpatient clinic at Songklanagarind Hospital. Results: Overall, 386 patients diagnosed with type 2 diabetes were enrolled (55.7% female; mean age, 63.3 years; median duration of type 2 diabetes, 7 years; median visit in 5 years of each patient, 44 visits). Prevalence of laxative prescriptions was 16.6%. Rate of laxative prescriptions was 1.7% within 5 years. Patients with no diagnosis constipation according to ICD-10 about 81.2%. The statistically significant factors associated with laxative prescriptions in diabetic patients were age, number of hospital visit in 5 years, duration of type 2 DM disease, height, diastolic blood pressure, hemoglobin, hematocrit, serum uric acid, and glomerular filtration rate. Conclusions: Most laxative prescribed diabetic patients were without written diagnosis of constipation. Factors associated with laxative prescriptions were age, number of hospital visit, duration of type 2 DM disease, height, diastolic blood pressure, hemoglobin, hematocrit, serum uric acid, and glomerular filtration rate.

A Terapia Comunitária Integrativa na abordagem da saúde mental na atenção primária: um relato de experiência

The Integrative Community Therapy (ICT), in addition to being a therapeutic method, is considered a community space to user embracement, where people can share their sufferings, life experiences, knowledge, problems, tough situations, victories and overcoming stories. The objective of this work is to report the experience and present the process of an ICT group’s insertion in a primary care unit located in Curitiba-PR. The themes and achievements presented by the participants are discussed, as well as the role of the primary care professional as a therapist in an ICT circle, and its reverberations in the workplace and clinical practice. It is concluded that ICT has great value because it can be understood as a technology for mental health, as well as a collaborative practice of social intervention, given the greatness of its possibilities since it empowers the community in solving their problems, and humanizes the work of the health team.

Comparison of Blood Pressure Control in Hypertensive Patients from Primary Care Units of University Hospital and Community in Southern Thailand

Background: Hypertension (HT) is the most common condition seen in primary care. The proportion of patients with wellcontrolled HT reflects the quality of care in a given setting. Objective: To compare the proportion of participants with controlled blood pressure (BP) in four primary care units (PCUs) in Hat Yai, Songkhla, Thailand. Materials and Methods: Data concerning demography and antihypertensive drug usage were collected from the medical records of 1,690 patients in four PCUs (Songklanagarind Hospital, Municipal School 4, Banpru Municipality, and Kho Hong Municipality) between January 2019 and May 2019. The factors associated with uncontrolled HT were assessed using multiple logistic modeling and reported in terms of odds ratios and corresponding 95% confidence intervals (CI). Results: The proportion of patients with controlled HT in the four PCUs and their corresponding 95% CI were 92.1% (90.8 to 93.6), 96.2% (90.3 to 98.7), 88.2% (84.3 to 90.1), and 74.5% (66.8 to 81.2). Of the total number of patients with controlled HT, 64.4% were female. The odds ratios and the 95% CI of the significantly associated factors with uncontrolled HT were PCU of site 3 and 4 (1.7, 1.1 to 2.6 and 3.0, 1.8 to 5.1), age of 65 years or older (0.7, 0.5 to 0.9), and dyslipidemia (0.7, 0.5 to 1.0). Conclusion: There were differences in quality of care among the PCUs, and they are associated with patient age and comorbidities like dyslipidemia. Keywords: Hypertension, Essential hypertension, Hypertensive treatment, Blood pressure, Primary care unit