Complaints In Primary Care Research Articles

Trazodona no Tratamento da Insónia: Qual a Evidência?

INTRODUÇÃO: A insónia constitui uma queixa frequente nos cuidados de saúde primários, com um impacto negativo na qualidade de vida dos utentes. Assim sendo, o seu tratamento adequado é fundamental. A trazodona é um fármaco que tem sido amplamente usado no tratamento da insónia, apesar de estar apenas aprovado, pelo INFARMED e Food and Drug Administration (FDA), para o tratamento da depressão, sendo relevante rever a evidência que suporta este seu uso off-label.METODOLOGIA: Com recurso a sites de medicina baseada na evidência pesquisaram-se meta-análises, revisões sistemáticas, ensaios clínicos e guidelines, publicadas nas línguas inglesa e portuguesa entre 19/05/2008 e 19/05/2018, usando os termos MeSH “Trazodone” e “Sleep Initiation and Maintenance Disorders” e as palavras-chave “Trazodone” e “Insomnia”.RESULTADOS: Foram incluídos na revisão 10 artigos: 2 meta-análises, 3 revisões sistemáticas, 2 ensaios clínicos e 3 guidelines. As meta-análises revelaram que a trazodona é eficaz no tratamento da insónia (nível de evidência -NE- 2), o mesmo se observou nos ensaios clínicos (NE 2) e em duas revisões sistemáticas (NE 2), com a terceira revisão referindo ausência de evidência para retirar conclusões. Relativamente às guidelines, duas suportam o uso da trazodona (Força de Recomendação -FR- B e FR C) enquanto a terceira sugere a sua não utilização (FR B).CONCLUSÃO: Existe evidência limitada de que a trazodona é eficaz no tratamento da insónia em indivíduos com idade ? 18 anos - força de recomendação B. É, assim, importante, que no futuro, sejam realizados mais estudos para reforçar o uso de trazodona no tratamento da insónia.

Evaluating low back pain in adolescents.

Low back pain in adolescents is a common complaint in primary care. With an average prevalence rate of 40%, adolescent low back pain correlates with greater healthcare use, higher incidences of adult back pain, and negative effects on overall well-being. A thorough history and physical examination can increase early detection and accurate diagnosis while ensuring the judicious use of diagnostic modalities. Although underlying serious pathology is rare in adolescents with low back pain, clinicians should recognize specific signs and symptoms that necessitate urgent evaluation and intervention. This article emphasizes the value of using a thorough history and physical examination to guide the initial diagnostic workup and to enhance the early detection and accurate diagnosis of adolescents who present with low back pain.

Mapping the undergraduate dermatology curriculum: a useful tool towards implementation of national recommendations.

Despite the high prevalence of skin complaints in primary care and secondary care, dermatology undergraduate (UG) education remains inconsistent across medical schools. The British Association of Dermatologists (BAD) published a revised national UG curriculum in 2016 to guide UK medical schools on the minimum competencies required in dermatology. The aim of the study was to determine the alignment of the BAD UG curriculum with the dermatology curriculum of the University of Nottingham School of Medicine. A curriculum mapping study was undertaken with the development of an electronic searchable database tool to map key areas. Of the 70 intended learning outcomes (ILOs) for dermatology in the medical school, 55 (79%) were mapped to the BAD curriculum, while 14 (20%) required modifications to align them with the BAD ILOs. Two BAD ILOs were unspecified in the current curriculum, and one was deemed redundant. Curriculum mapping is a useful tool to standardize local dermatology ILOs to national recommendations and provides transparency to stakeholders for implementation of the dermatology curriculum.

TF15 General Pediatrics for the Emergency Physician

Primary objective: Increase the general pediatrics knowledge base of EM providers. Secondary objective: Increase both provider and patient satisfaction and decrease repeat ED visits for common pediatric primary care complaints. Eight modules of general pediatric topics were developed by emergency physicians trained in general pediatrics or pediatric emergency medicine. Emergency physicians who complete the modules will be asked to complete a pre-test survey regarding their comfort with each of the topics. Each module contains a “Knowledge Check” that reviews the high yield information presented in that module and will assess the retention of the information. The emergency physician will then take a post-test survey to assess their comfort with the topics after completion of the modules. The pre- and post- test surveys assessing provider comfort will be compared using a Likert scale. Preliminary data collection is currently ongoing. Nonurgent complaints make up a significant number of emergency department visits for pediatric patients. Many of these complaints and questions are out of the scope of general emergency medicine practice. By expanding the general pediatric knowledge base of EM providers, they will provide better care to their patients and feel comfortable addressing basic primary care pediatrics questions. Ability to address these complaints will hopefully lead to increased patient and provider satisfaction along with the goal of decreasing ED recidivism for primary care-focused complaints.

Evaluating and managing low back pain in primary care.

Low back pain (LBP) is one of the most frequent patient complaints in primary care. Common LBP diagnoses include nonspecific LBP, radicular pain, lumbar-disk herniation, spinal infection, and ankylosing spondylitis. A thorough history and physical exam are imperative. LBP treatment is multifactorial and blends pharmacologic and nonpharmacologic approaches.

Are probiotics useful in the treatment of chronic idiopathic constipation in adults? A review of existing systematic reviews, meta-analyses, and recommendations.

Chronic idiopathic constipation (CIC) has emerged as common problem for contemporary gastroenterology and is one of the most frequent complaints in primary care. Chronic idiopathic constipation significantly affects patients’ quality of life and has an impact on global health and economy. Functional gastrointestinal disorders and bowel disorders, according to Rome IV criteria, result from inappropriate gut-brain interactions. The pathophysiology is complex and poorly understood, with evidence accumulating that gut microbiota can be implicated in the development and function of the enteric nervous system. Gut bacteria modulate gut barrier function, short chain fatty acid synthesis, and bile acid metabolism, factors which play roles in the gut peristalsis regulation. The high prevalence of CIC, with poor treatment outcomes, warrants searches for new forms of therapy, including probiotic therapies. Probiotics are often recommended by medical practitioners, but evidence-based utility in adults with CIC is uncertain. Recommendations/guidelines are often based on results from individual studies, rather than meta-analyses or umbrella reviews. Additionally, meta-analyses often indicate a group of probiotics rather than individual strains, and they create difficulty for physicians in making therapeutic choices. More CIC patient randomised clinical studies utilising well-defined strains, or combinations, are necessary.

Utilization of Health Care Resources by the Amish of a Rural County in Nebraska

The medical needs of the New Order Amish (NOA) remain poorly understood. The NOA community in Pawnee County, Nebraska was founded in 2011 by members from across the Midwest. Understanding what this community wants from their medical providers informs how rural hospitals may best serve the needs of growing NOA populations. To address this, the current utilization of the closest healthcare resource to community were assessed. Medical records data for Amish patients were obtained at Pawnee County Memorial Hospital and Rural Health Clinic from 2011 to 2016. Subjective data were obtained by surveys and interviews administered to Amish in Pawnee County. The 422 complete interactions in the medical record covered most primary care complaints. The fifteen survey respondents valued direct interaction with providers and expressed concerns about cost, emergencies, and access to obstetric practice. Surprisingly, though surveys indicated minimal use of health establishments for many common health complaints, medical records indicated frequent doctor visits for myriad reasons. Naturalistic books were the most utilized source of health information. The NOA utilize formal medicine, but may feel excluded in medical decision-making. They desire better access to obstetric care and culturally sensitive medical practice. Providers should ensure appropriate communication to increase healthcare-related comfort of this underserved population.

Chronic Abdominal Pain and Rectal Bleeding: A Missed Opportunity

Abdominal pain and rectal bleeding among men who have sex with men are common complaints treated in primary and urgent care settings. These common primary care complaints—often vague and recurrent—require a comprehensive and thorough investigation of the patient’s history and lifestyle to ensure an accurate diagnosis and treatment. This case highlights the importance of removing barriers to care from the patient’s and provider’s perspectives to more accurately diagnose and effectively treat common symptoms experienced among men who have sex with men.

See-Hear-Feel-Speak: A Protocol for Improving Outcomes in Emergency Department Interactions With Patients With Autism Spectrum Disorder.

The presentation of children and adolescents with autism in the emergency department (ED) poses a unique set of challenges to clinicians and their teams, which have not yet been met. Children and adolescents with autism spectrum disorder (ASD) are more likely than their age and ethnically matched counterparts to visit both pediatric and general EDs and are more likely to use it for primary care complaints and dental care and to present for psychiatric concerns including suicidality. Despite the higher relative frequency, individuals with ASD demonstrate lower patient satisfaction, lower healthcare self-efficacy, and higher odds of unmet healthcare needs related to physical health, mental health, health maintenance, and vaccination. This can be ameliorated by simple strategies regarding communication, sensory and environmental modification, and distraction. After performing a literature review of existing evidence-based recommendations via PubMed as well as resources from autism advocacy and self-advocacy groups, we compiled a 4-step system: "See-Hear-Feel-Speak" an approach conducive to learning with the goal of enabling clinicians and their teams to facilitate patient-centered encounters with pediatric patients with ASD. The protocol meets the practicality requirements defined by published research.

Narcolepsy and Other 'Central Disorders of Hypersomnolence'

Narcolepsy and Other 'Central Disorders of Hypersomnolence' Abstract. 'Excessive daytime sleepiness', 'hypersomnia' in the sense of prolonged sleep need, 'tiredness' or 'fatigue' are frequent complaints in primary care, requiring a careful separation in view of a correct diagnostic. After exclusion of various internistic and neurologic causes by clinical and laboratory investigations and after exclusion of sleep apnoea syndrome or other causes of disturbed sleep by polysomnography, the ambiguous group of 'Central Disorders of Hypersomnolence' remains, including narcolepsy with and without cataplexy, idiopathic hypersomnia, and non-organic hypersomnia. Due to the important therapeutic consequences, these diseases must be differentiated and distinguished from insufficient sleep and from chronic fatigue syndrome, often requiring interdisciplinary diagnostics including objective assessment of the reported complaints.

Dor lombar e transtornos mentais comuns na Estratégia Saúde da Família: uma associação pouco reconhecida

Objetivo: Descrever o perfil sociodemográfico dos pacientes atendidos na Estratégia Saúde da Família de quatro capitais brasileiras (Rio de Janeiro, São Paulo, Porto Alegre e Fortaleza) com dor lombar e investigar a associação entre dor lombar e depressão, ansiedade e somatização. Métodos: Estudo de corte transversal com 1857 pacientes atendidos nos anos de 2009 (setembro a novembro) e 2010 (junho a agosto). Instrumentos: rastreio de somatização (SOMS-2), avaliação de ansiedade e depressão (HAD), Questionário Geral do Paciente, para dados sociodemográficos e o Formulário do Profissional Assistente, com as informações referentes as consultas. A dor lombar foi analisada a partir da frequência de três diferentes formas de apresentação: queixa autorreferida pelo paciente, sintoma registrado pelo médico e diagnóstico de lombalgia confirmado pelo médico. Resultados: 77,3% eram mulheres com mais de quatro anos de estudo e renda per capita inferior a um salário mínimo e meio. Encontramos associação significativa de queixa de dor lombar com ansiedade (OR=1,5, 95% IC 1,02-2,16) e somatização (OR=1,8, 95% IC 1,12-2,88), mas não com depressão. Pacientes que apresentavam queixa de dor lombar, porém sem registro do sintoma pelo médico, apresentaram associações ainda mais fortes com ansiedade (OR=1,6, 95% IC 1,03-2,63) e somatização (OR=2,3, 95% IC 1,33-3,99). A confirmação do diagnóstico de dor lombar pelo médico não se associou significativamente com nenhum transtorno. Conclusão: Considerando a dor lombar como uma das queixas de maior prevalência na Atenção Primária e sua associação significativa com ansiedade e somatização, recomenda-se a abordagem da ansiedade e somatização em pacientes com queixa de dor lombar.

P.025 Is this headache normal?: Assessing electronic referrals for headache from primary care physicians

Background: Headache is one of the most frequent complaints in primary care. We reviewed headache questions submitted to an electronic consultation service in Ontario to classify the types of headaches and describe the questions being asked. We also identified reasons why answers were not retrievable within UpToDate, an online clinical resource. Methods: 65 headache eConsults were further divided into 85 questions and categorized by headache type and question theme. Questions were manually searched within UpToDate to determine if they could be answered using this resource. The intent to refer the patient for a face-to-face referral after the eConsult was collected. Results: The top classifications were migraine, unclassified headache, and exertional and/or coital headache. The themes -identified were medication questions (41.7%), investigation questions (33.3%), clinical concerns despite normal neurologic exam and/or imaging (15.5%); and abnormal imaging findings (9.5%). Answers to 40.1% of the questions were not retrievable in UpToDate. The main reason for irretrievability was an unusual presentation. Only 33.8% of eConsults resulted in a face-to-face referral to a specialist. Conclusions: Although electronic resources may be useful in some cases, clinical nuances cannot be accounted for. By providing physicians with rapid access to specialists, eConsult services may obviate the need for formal, face-to-face referrals.

Hoarseness

Hoarse voice, or dysphonia, is a common presenting complaint in primary care and an important source of patient morbidity. The underlying pathology can vary from benign to immediately life-threatening and structured clinical assessment is essential in differentiating causes and determining management. In this article, we discuss the clinical approach, aetiology and management of the wide range of conditions that lead to dysphonia and provide guidance on referral to specialist care.

10-year trajectories of pain in early knee and hip osteoarthritis; the check study

Purpose: To determine subgroups of patients with homogenous patterns of pain over 10 years follow-up, among patients with early hip and/or knee complaints in primary care. Next, baseline demographics and number total joint replacements over time will be compared between groups. Methods: Data from the CHECK cohort (Cohort Hip and Cohort Knee) were used. For this cohort, 1002 patients between 45 and 65 years at or within 6 months from their first consultation at a general practitioner for symptoms of their hips and/or knees, not explained by other diseases, were included and followed for 10 years. A numeric rating scale (NRS) for perceived pain was obtained at baseline and after 2, 5, 8 and 10 years, or until total joint replacement. Using these longitudinal data, subgroups of patients with comparable trajectories over time were identified using Latent Class Growth Analysis (LCGA). Models with 3–6 classes when using linear, cubic and quadratic trajectories were evaluated using Mplus software. Results: At baseline, the 998 subjects (79% women) with ≥2 NRS data points available had a mean age of 55.9 ± 5.2 years and a mean BMI of 26.2 ± 4.0 kg/m2. In total, 410 patients reported knee pain only (41%), 173 hip pain only (17%), and 415 reported both knee and hip pain (42%) at baseline. On a joint level, 156 knees and 160 hips had KL-grade ≥ 2 at baseline. The by LCGA derived models of 3 groups with a linear trajectory and of 6 groups with a cubic trajectory resulted in comparable goodness of fit indicators (Bayesian Information Criteria 17991 vs. 17927, Akaike Information Criteria 17927 vs. 17761, and entropy 0.694 vs. 0.683 for the 3 and 6 group models, respectively). Both models and the corresponding trajectories are presented in the Figure. Clinical characteristics and number of total joint replacements over time for each of the groups are presented in the Table. In the 3 group model, the ‘high pain trajectory’ (group 2, blue line) had the highest percentage of patients with knee and hip complaints, females, total joint replacements, and the highest mean BMI. The ‘low pain trajectory’ (group 3, green line) had the highest percentage of patients with only hip and only knee complaints, and the lowest mean BMI. In the 6 group model, the ‘always high pain trajectory’ (group 1, red line) had the highest percentage of females and total joint replacements (knees more pronounced than hips), and the highest mean BMI. The ‘always low pain trajectory’ (group 5, brown line) had the highest percentage of patients with only knee complaints and the lowest mean BMI. The ‘decreasing pain trajectory’ (group 2, blue line) had the highest percentage of patients with only hip complaints. The ‘fluctuating high pain trajectories’ (groups 3 and 4, green and pink lines) had the highest percentage of females and patients with knee and hip complaints. Conclusions: The 6 group model identified more extreme groups with lower minimal and higher maximal prevalence of the presented clinical characteristics. In the end, the conclusion drawn from the two models appear similar; Patients presenting with both knee and hip complaints had less favorable pain trajectories over the following 10 years and the number of total joint replacements was the highest in the groups always reporting high pain scores.TableClinical characteristics and number of total joint replacements for two modelsModelGroup (line colour in Figure)NKnee pain onlyHip pain onlyKnee and hip pain% femalesBMI (kg/m2)TKP during follow-upTHP during follow-up3 groups with a linear trajectoryGroup 1 (red)351130 (37%)60 (17%)161 (46%)82%26.4 ± 3.915 (4%)28 (8%)Group 2206682811084%27.6 ± 4.61529(blue)(33%)(14%)(53%)(7%)(14%)Group 34412128514475%25.3 ± 3.6417(green)(48%)(19%)(33%)(1%)(4%)6 groups with a cubic trajectoryGroup 117656299186%27.7 ± 4.71231(red)(32%)(17%)(52%)(7%)(18%)Group 2371581470%26.1 ± 3.402(blue)(41%)(22%)(38%)(0%)(5%)Group 3882595483%26.3 ± 4.258(green)(28%)(10%)(61%)(6%)(9%)Group 414260196386%26.5 ± 4.187(pink)(42%)(13%)(44%)(6%)(5%)Group 5289146618271%25.0 ± 3.4112(brown)(51%)(21%)(28%)(0%)(4%)Group 62661084711179%26.2 ± 3.8814(yellow)(41%)(18%)(42%)(3%)(5%) Open table in a new tab

The fatigue perception and its role in patient management

Objective:
 Fatigue is one of the most common complaints in primary care. Patients' fatigue
 perceptions may be very different from each other. We aimed to determine the
 fatigue perception and its relationship with fatigue severity, sociodemographic
 characteristics, history, physical examination and laboratory findings in
 patients with complaints of fatigue.Methods:
 This study was carried out as a cross-sectional study in a tertiary family
 medicine clinic between June 2016 and June 2017. All patients aged 18 years and
 over who were complaining of fatigue for at least 1 month were invited to
 study. Fatigue perceptions of volunteers who agreed to participate in the study
 (n = 116) were evaluated with a structured form prepared by researchers.
 Fatigue severity was measured using Fatigue Severity Scale and Checklist
 Individual Strength surveys. Patients’ records including history, physical
 examination and laboratory results were included in the study.Results:
 The mean age of participants was 29.5 ± 9.8 years and 87.9% were female. We
 asked patients “what do they mean by fatigue?” and “what fatigue complaints
 contain?”. Tiredness, lack of energy and sleeplessness - somnolence - desire to
 sleep were the most common answers. Expression that had the highest score from
 the fatigue severity scales was the needle hurt sensation for all body. In
 patients’ records, the most common findings in patients with fatigue were
 vitamin D deficiency (84.5%), sleeping problem (72.8%) and depression (69%).
 When the relationship between fatigue perceptions and possible etiologic
 factors was examined, it was observed that most of them were related with the
 depression risk. As a result, it was observed that seven different findings
 affected nineteen different fatigue perceptions.Conclusion:
 In this study, fatigue perception has been shown to be as important as other
 features. The physicians should investigate its content and try to understand
 the patient.

How to choose the most appropriate cognitive test to evaluate cognitive complaints in primary care

BackgroundDespite the wealth of research devoted to the performance of individual cognitive tests for diagnosing cognitive impairment (including mild cognitive impairment and dementia), it can be difficult for general practitioners to choose the most appropriate test for a patient with cognitive complaints in daily practice.In this paper we present a diagnostic algorithm for the evaluation of cognitive complaints in primary care. The rationale behind this algorithm is that the likelihood of cognitive impairment -which can be determined after history taking and an informant interview- should determine which cognitive test is most suitable.MethodsWe distinguished three likelihoods of cognitive impairment: not likely, possible or likely. We selected cognitive tests based on pre-defined required test features for each of these three situations and a review of the literature. We incorporated the cognitive tests in a practical diagnostic algorithm.ResultsBased on the available literature, in patients with complaints but where cognitive impairment is considered to be unlikely the clock-drawing test can be used to rule out cognitive impairment. When cognitive impairment is possible the Montreal cognitive assessment can be used to rule out cognitive impairment or to make cognitive impairment more likely. When cognitive impairment is likely the Mini-Mental State Examination can be used to confirm the presence of cognitive impairment.ConclusionsWe propose a diagnostic algorithm to increase the efficiency of ruling out or diagnosing cognitive impairment in primary care. Further study is needed to validate and evaluate this stepwise diagnostic algorithm.

Clinical anatomy and stabilizers of the glenohumeral joint

Shoulder pain and instability are common complaints in primary care and orthopaedic sports medicine clinics. Diagnoses and treatment can prove to be a challenge for practitioners, especially if the underlying normal and pathologic anatomy is not well understood. The glenohumeral joint is a multiaxial synovial ball and socket joint that permits a wide range of motion at the cost of inherent stability. To provide support to the joint, osseous and capsuloligamentous static stabilizers function in concert with dynamic muscular stabilizers. This article will review these critical structures and provide an anatomic guide to restore function and stability in the clinical setting.

The future role of receptionists in primary care.

The postmillennial family practice has moved far beyond its cottage industry origins. The broader range of services and treatments on offer in modern primary care are maintained by sophisticated medical technologies and an equally diverse and specialised set of care providers. In addition, the service is relied on to promote health and deal with a wider scope of social and psychological issues in the face of disappearing social care and increasing fragmentation of families.1 The growing complexity of the primary care environment and the increasing expectations of patients and policymakers are placing huge demands on the primary care workforce. Recent reports on the challenges and opportunities facing primary care in the UK acknowledge that, to meet these demands, we must realise the potential of all members of the primary care team, including both clinical and non-clinical staff.2,3 Arguably the most visible among the primary care workforce are receptionists, required to work under unprecedented levels of pressure and scrutiny, yet without any concurrent change in their training or support. Their position at the point of entry to the healthcare system means they are the most accessible member of the care team4 and have a significant influence on patients’ perception of their care. They frequently embody the frustrations of patients: a recent survey of complaints in primary care found those concerning receptionists were responsible for nearly half of upheld complaints, the largest figure of any staff group.5 This dissatisfaction with reception staff can have serious implications for non-attendance, increased A&E visits, and health outcomes.6 Apparently overlooked by policymakers and undervalued by GPs and patients, receptionists are viewed chiefly as either administrators, undertaking clerical duties …

Evaluation of common breast complaints in primary care

Evaluation of common breast complaints in primary care

Evaluation of common breast complaints in primary care.

Discovery of a breast mass, nipple discharge, or breast pain is a common, anxiety-producing occurrence for many women. Although most irregularities are benign, every woman presenting with a breast complaint should be evaluated to exclude or establish a diagnosis of cancer. The patient visit to the provider for a breast complaint can also present an opportunity for the NP to address and update any needed breast screenings.