First Point Of Medical Contact Research Articles

TRANSFORM-HF Trial: Choice of loop diuretic in acute heart failure does not matter!

ABSTRACT The major clinical manifestations of heart failure (HF) are due to fluid retention and congestion, and thus, therapy targeting congestion plays a central role in HF management. Furosemide is by far the most commonly prescribed loop diuretic. However, data primarily derived from observational and small randomized trials point toward potential advantages with torsemide use including improvement in functional status, survival, and hospitalization for HF. The TRANSFORM-HF study aimed to answer a pragmatic query faced by physicians managing HF – Does the choice of loop diuretic matter in HF? There was no benefit of torsemide over furosemide in this large study of >2800 patients for mortality, hospitalization, and quality of life. Though, there were a few shortcomings of the study, the results are in sync with current HF guidelines which do not advocate the use of one loop diuretic or other. Hence, the focus in acute HF should be on optimizing the diuretic dose and other guideline-based therapies rather than the type of diuretics. Recent trials of acetazolamide and other diuretics have shown benefits when used in conjunction with loop diuretics. Since the primary care physician is often the first point of medical contact, the manuscript aims to provide insights into their practice. The message is clear that in acute heart failure, there is no benefit of choosing the type of loop diuretic and impetus should be on adding other class diuretics if needed as well as initiating other guideline-directed medical therapies.

Sjogren's Syndrome: Multidisciplinary Approach to Diagnosis and Management

Purpose: Sjögren’s syndrome (SS) is a chronic and progressive multisystem autoimmune disease typically managed by rheumatologists. Diagnostic delays are common, due in large part to the non-specific and variable nature of SS symptoms and the slow progression of disease.
 Methodology: This article reviews current understanding of the clinical manifestations, diagnosis and treatment of Sjögren's syndrome and its attendant ocular manifestation. Sjögren's syndrome is a chronic inflammatory disorder of the exocrine glands with multiple non exocrine features. It is found predominantly in middle-aged women but exists throughout the population. The diagnosis of Sjögren's syndrome can be challenging because the cardinal sicca symptoms may be subclinical or attributed to other causes, such as medications or aging. Differential diagnosis of Sjögren's syndrome can be confounded by the multiple exocrine manifestations in the mouth, eyes, ears, nose, skin, vagina, and respiratory and gastrointestinal tracts. Characteristics of SS are dry eye and dry mouth, which are typically the earliest presenting complaints, eye care clinicians such as the optometrists and dental professionals are often the first point of medical contact and can provide critical collaboration with rheumatologists to facilitate both timely diagnosis and ongoing care of patients with SS.
 Findings: Current diagnostic criteria advocated by the American College of Rheumatology are predicated on the presence of signs/symptoms suggestive of SS along with at least two objective factors such as traditional biomarker positivity, salivary gland biopsy findings, and/or presence of keratoconjunctivitis sicca. Timely diagnosis of SS requires appropriate clinical vigilance for potential SS symptoms, referral and collaborative communication among rheumatology, optometrists, ophthalmology, and oral care professions.
 Unique Contribution to Theory, Practice and Policy: It is concluded that optometrists can now identify Sjogren’s patients earlier in their dry eye population with a new advanced diagnostic test Sjo,the laboratory test designed for early detection of Sjogren’s syndrome, has been available from Nicox for use by eye care professionals since November,2013. Optometrists have a role to play in the management of ocular manifestations of Sjogren’s syndrome. Such symptoms can lead to discomfort, blurred vision, and visual fatigue if not attended to immediately.
 For people with immune system disorder, inflammation of tear-secreting glands reduces tear production, resulting in chronic dry eyes. Prescription eye drops such as Tears Naturale, Cyclosporine (Restasis) or Lifetegrast(Xiidra) may be recommended by the eye doctor if you have moderate to severe dry eyes.

Seasonal Variation of Peritonsillar Abscess Presentation to an Emergency Department in an Atlantic Canadian Climate: A Retrospective Review.

Patients with a peritonsillar abscess (PTA) often present to emergency departments as the first point of medical contact. Upper respiratory tract infections (URTIs) are more frequent in the winter. Therefore, we hypothesize that the incidence of PTAs will be more frequent in colder winter months as well. This is the first study assessing the seasonal variation and epidemiology of PTA presentations to an emergency department in Atlantic Canada, home to a unique maritime climate. A retrospective cohort study was conducted through a chart review of all patients who presented to the Saint John Regional Hospital Emergency Department from January 1, 2015, to December 31, 2020. Patient characteristics, treatment, and microbiology were reported. A chi-square goodness-of-fit test assessed the seasonal variation of PTA. Pearson correlations assessed PTA incidence per mean monthly temperature and humidity. A total of 75 patients were included. 57.3% were male and 42.7% were female, with a mean age (±SD) of 35.9 ± 14.0. Most patients presented afebrile (82.7%, cutoff ≥ 38.0°C). Approximately half of all patients had an elevated WBC count (49.3%, cutoff ≥ 10.9 × 109). The most common bacteria isolated were Streptococcus species followed by anaerobic bacteria (17.9%). No significant variation was found with respect to season (X2(3) = 1.0, P = .801), temperature (r(70) = 0.198, P = .096), or humidity, (r(70) = 0.063, P = .599). This study did not find a seasonal variation of PTA in a maritime climate. These findings question the anecdotal hypothesis that PTA is associated with progression from acute URTIs and therefore would be more common in the winter months.

Abstract WP52: Emergency Medical Services Documentation Of Stroke Care In The United States

Introduction: Emergency medical services (EMS) are often the first point of medical contact for patients suffering from acute stroke. EMS must identify and triage patients appropriately for them to receive the best care. Several prehospital stroke scales exist to assist prehospital providers in identifying acute stroke in the field, but their real-world applications are poorly characterized. Understanding prehospital stroke treatment provides the opportunity to identify areas of improvement across the stroke continuum of care. Methods: We retrospectively reviewed data from the 2019 National EMS Information System (NEMSIS) dataset from the United States of America. NEMSIS contains standardized information reported by states on EMS activations. Observations included were transported by ground ambulance and had an EMS provider documented stroke assessment with a primary impression of stroke or TIA. Observations excluded interfacility transfers and were limited to activations that documented pre-notification of hospital-based stroke specialty team resources. Results: EMS providers used a variety of stroke scales in 2019. Of 30,436 observations, the Cincinnati Prehospital Stroke Scale was the most common with 17,462 uses (57.37%). The F.A.S.T. Exam came second with 3366 (11.05%) uses and the Los Angeles Prehospital Stroke Scale with 3,146 (10.33%). EMS providers recorded “Other Stroke Scale Type” 4362 (14.33%) times. EMS providers documented either a negative or inconclusive stroke score 10,390 (34.13%) times. EMS documented stroke specialty team notifications 17,391 (57.14%) of the time. EMS did not pre-notify the stroke specialty team for 13,045 (42.86%) of patients. 3,576 (27.41%) of these patients received a negative stroke scale score, 1,745 (13.38%) inconclusive and 7,724 (59.21%) positive respectively. Among cases where EMS notified a stroke specialty team 1,590 (9.14%) received a negative, 2,479 (14.25%) an inconclusive and 13,322 (76.60%) a positive stroke scale score. Conclusion: US EMS stroke care documentation has substantial variability and is ripe for standardization. This fact necessitates research to understand its causes and achieve pre-hospital stroke care optimization on a national scale.

Risk factors for potential drug-drug interactions of statins in patients with acute coronary syndrome

The aim of our study was to assess risk factors for potential drug-drug interactions (pDDIs) of statins across different phases of treatment of acute coronary syndrome (ACS) patients: from the point of first medical contact to the coronary angiography (first phase), after coronary angiography to the last day of hospitalization (second phase) and at discharge from hospital (third phase). This was a post hoc analysis of the data collected during the retrospective observational cohort study conducted at the Clinic for Cardiology of the Clinical Centre Kragujevac, Serbia. Patients prescribed statins were identified from the original study population: 156, 240 and 236 patients for the first, second and third phases, respectively. At least one statin pDDI was present in 113 (72.4%), 161 (67.1%) and 139 (58.9%) patients in the first, second and third phases, respectively. Heart failure, arrhythmias after ACS, CRP, triglycerides, length of hospitalization, number of prescribed drugs, antiarrhythmic drugs, and clopidogrel seem to increase the risk of statin pDDIs in at least one treatment phase. Physicians should be vigilant to the possibility of statin pDDIs in ACS patients who have factors that may increase their rate.

Characteristics of children and adolescents presenting to the emergency department with self-inflicted injury: Retrospective analysis of two teaching hospitals

Data on Taiwanese adolescents with self-inflicted injuries are limited. We describe the epidemiology of children and adolescents visiting the emergency department for self-inflicted injuries in two geographically distinct teaching hospitals. Medical records of children 0-18 years old who visited the emergency department of Taipei Tzu Chi Hospital and Chi Mei Medical Center, Tainan between 2016 and 2019 coded with relevant diagnoses were reviewed. Visits with documented self-inflicted injury were included. During the 4-year period, 62 children made 74 emergency visits for self-inflicted injury. A total of 88% of visits were made by children with a psychiatric diagnosis, with depressive disorders being the most common (57%). Interpersonal relationship issue was cited as a trigger for self-harm in 49% of visits. Adjusted for annual visit volumes, self-harm visits per 10,000 pediatric emergency visits increased nearly 5 fold between 2016 and 2019, with the most prominent increase in the final year. Poisoning was the most common mechanism of injury and was frequently used by females, as compared to males who tended to jump from heights. Up to 96% of adolescents with previous self-harm seen at the emergency department had sought psychiatric help in the past year. Urban-rural inequity in mental health resource utilization was observed. Visits to the emergency department for self-inflicted injuries among children and adolescents increased, most remarkably in 2019, for both hospitals. Intentional poisoning with prescription and over-the-counter medications was the most common method. There was a high prevalence of psychiatric disorders in our study population. As the emergency department is likely the first point of medical contact for such visits, emergency personnel should be trained appropriately on managing such patients.

A survey of the involvement of primary care doctors in HIV prevention and care in a low-prevalence, high-income setting

BackgroundIn high-income countries with a low HIV prevalence, primary care doctors are likely the first point of medical contact for people at high risk of HIV. One of the key factors for successful implementation of preventive measures is the cooperation of primary healthcare providers. Hong Kong’s population mostly seek primary care in the private sectors. Our study evaluated the involvement of private primary healthcare providers in HIV prevention and care.MethodsA cross-sectional postal structured questionnaire was administered to 1102 private primary care doctors in Hong Kong in December 2017. Responses were received via postal mail, fax or online. Non-respondents received a phone-call reminder to complete the survey. Descriptive analyses were performed for all the question items. Chi-square test was used to assess the association between participants’ level of involvement in HIV prevention and care and their demographics and medical practice characteristics.ResultsThe response rate was 17.9% (197/1102). Most of the respondents were Chinese (95%) and have obtained their primary medical qualifications in Hong Kong (72%). More than half of the doctors have practiced in the private sector for more than 20 years (54%). Six aspects were used to evaluate practices or involvements in HIV prevention or care: Most of the responding doctors had offered advice (61%) and/or HIV test (76%) to patients with high-risk behaviors. However, fewer doctors had diagnosed HIV (27%), provided care for HIV positive patients (21%), reported HIV cases (19%) or prescribed antiretrovirals (4%). Nine (4.5%) did not answer all six questions on their practices or involvements in HIV prevention or care. The remaining respondents were then categorized into no/low involvement group and high involvement group. Overall,71% had no/low involvement (133/188) compared to 29% who had high involvement (55/188). Factors associated with high involvement included being in the 50–59 age group (OR: 2.48, 95% CI: 1.12–5.5), and belonging to a large practice (OR: 3.16, 95% CI: 1.4–7.12).ConclusionsOverall, most private primary care doctors in Hong Kong have no or low involvement in HIV prevention and care. However, most were willing and experienced in providing general preventive services, such as HIV testing and advice.

South African paramedic perspectives on prehospital palliative care

BackgroundPalliative care is typically performed in-hospital. However, Emergency Medical Service (EMS) providers are uniquely positioned to deliver early palliative care as they are often the first point of medical contact. The aim of this study was to gather the perspectives of advanced life support (ALS) providers within the South African private EMS sector regarding pre-hospital palliative care in terms of its importance, feasibility and barriers to its practice.MethodsA qualitative study design employing semi-structured one-on-one interviews was used. Six interviews with experienced, higher education qualified, South African ALS providers were conducted. Content analysis, with an inductive-dominant approach, was performed to identify categories within verbatim transcripts of the interview audio-recordings.ResultsFour categories arose from analysis of six interviews: 1) need for pre-hospital palliative care, 2) function of pre-hospital healthcare providers concerning palliative care, 3) challenges to pre-hospital palliative care and 4) ideas for implementing pre-hospital palliative care. According to the interviewees of this study, pre-hospital palliative care in South Africa is needed and EMS providers can play a valuable role, however, many challenges such as a lack of education and EMS system and mindset barriers exist.ConclusionChallenges to pre-hospital palliative care may be overcome by development of guidelines, training, and a multi-disciplinary approach to pre-hospital palliative care.

Beyond Antibiotics: A Practical Guide for the Infectious Disease Physician to Treat Opioid Use Disorder in the Setting of Associated Infectious Diseases.

Infections are a common cause of hospitalization for patients with opioid use disorder (OUD), and hospital admissions are rising in the context of the worsening US opioid crisis. Infectious disease (ID) physicians are frequently the first point of medical contact for these patients. In this article, we discuss the integration of evidence-based management of OUD and patient-centered care of hospitalized persons with acute injection-related infections. We describe the following components of a comprehensive approach for OUD with inpatient ID consultations: (1) how to screen for OUD; (2) how to initiate the 3 US Food and Drug Administration-approved medications for OUD (buprenorphine, methadone, and extended-release naltrexone); (3) how to manage acute pain and opioid-related conditions; and (4) how to link and integrate ID and OUD treatment after hospital discharge. These strategies reduce unplanned discharges and increase completion of recommended antimicrobial regimens.

Towards artificial intelligence in mental health by improving schizophrenia prediction with multiple brain parcellation ensemble-learning

In the literature, there are substantial machine learning attempts to classify schizophrenia based on alterations in resting-state (RS) brain patterns using functional magnetic resonance imaging (fMRI). Most earlier studies modelled patients undergoing treatment, entailing confounding with drug effects on brain activity, and making them less applicable to real-world diagnosis at the point of first medical contact. Further, most studies with classification accuracies >80% are based on small sample datasets, which may be insufficient to capture the heterogeneity of schizophrenia, limiting generalization to unseen cases. In this study, we used RS fMRI data collected from a cohort of antipsychotic drug treatment-naive patients meeting DSM IV criteria for schizophrenia (N = 81) as well as age- and sex-matched healthy controls (N = 93). We present an ensemble model -- EMPaSchiz (read as ‘Emphasis’; standing for ‘Ensemble algorithm with Multiple Parcellations for Schizophrenia prediction’) that stacks predictions from several ‘single-source’ models, each based on features of regional activity and functional connectivity, over a range of different a priori parcellation schemes. EMPaSchiz yielded a classification accuracy of 87% (vs. chance accuracy of 53%), which out-performs earlier machine learning models built for diagnosing schizophrenia using RS fMRI measures modelled on large samples (N > 100). To our knowledge, EMPaSchiz is first to be reported that has been trained and validated exclusively on data from drug-naive patients diagnosed with schizophrenia. The method relies on a single modality of MRI acquisition and can be readily scaled-up without needing to rebuild parcellation maps from incoming training images.

Knowledge and attitude towards identification of systemic inflammatory response syndrome (SIRS) and sepsis among emergency personnel in tertiary teaching hospital

IntroductionAn emergency department (ED) is often the first point of medical contact for sepsis patient, which plays an important role in early identification and management of high-risk septic patients. The present study was aim to evaluate emergency personnel's knowledge and attitude toward identification and management of systemic inflammatory response syndrome (SIRS) and sepsis. MethodsThis cross-sectional study was conducted in a tertiary teaching hospital and recruited all emergency personnel. A validated questionnaire on knowledge and attitude towards identification and management of SIRS/sepsis was distributed among 120 emergency personnel. Data were analyzed using descriptive and inferential statistics. ResultsOverall finding founds emergency nurses and assistant medical officer appeared to have moderate knowledge in several important areas of SIRS/sepsis identification and management. Majority of the emergency personnel have neutral attitudes, as they do not give enough importance towards identification of patients with SIRS and sepsis. The present study finding found that knowledge of clinical criteria and management of SIRS/sepsis was highest among assistant medical officers (p=0.02) and bachelor's degree holders (p=0.02) with emergency experience more than 5 years (p=0.03). A trend toward an increase in knowledge of SIRS and sepsis is significantly correlated with positive attitudes. ConclusionThe emergency personnel demonstrated a moderate knowledge and neutral attitude toward identification and management of SIRS and sepsis. Therefore, the awareness and knowledge of SIRS and sepsis should be enhanced among emergency personnel in order to improve outcome.

Drug-drug interactions in patients with acute coronary syndrome across phases of treatment.

The objective of this study is to evaluate potential drug-drug interactions (pDDIs) and risk factors for pDDIs in three phases of an acute coronary syndrome (ACS) treatment: from the point of first medical contact to the coronary angiography (first phase), after coronary angiography to the last day of hospitalization (second phase), and at discharge from hospital (third phase). This retrospective observational cohort clinical study was conducted at the Clinic for Cardiology of the Clinical Centre Kragujevac, a public tertiary care hospital in Kragujevac, Serbia. Micromedex® interaction checker was used to detect pDDIs. This study included 245 ACS patients. All patients were exposed to at least one pDDI in all the phases of treatment. Mean total number of pDDIs was 9.47 ± 6.07, 10.11 ± 6.92, and 6.29 ± 3.66 in first, second, and third phases, respectively. Age, > 6h from the beginning of the symptoms to admission, primary PCI, STE-ACS, COPD, delirium, hyperlipidemia, hypertension, obesity, systolic blood pressure at admission, TIMI risk score at admission, ALT, LDL, number of physicians who prescribed drugs to a single patient, number of prescribed drugs, and various pharmacological classes increased risk of pDDIs. Mechanical ventilation, dementia, and drug allergy noted in the medical documentation protected against them. Effects of heart failure, diabetes, and aPTT depended on phase of treatment and severity of pDDI. In conclusion, physicians should be vigilant to the possibility of pDDIs in patients harbouring factors that may increase their rate.

Prompt Administration of Antibiotics and Fluids in the Treatment of Sepsis: A Murine Trial.

Sepsis, the acute organ dysfunction caused by a dysregulated host response to infection, poses a serious public health burden. Current management includes early detection, initiation of antibiotics and fluids, and source control as necessary. Although observational data suggest that delays of even a few hours in the initiation of antibiotics or IV fluids is associated with survival, these findings are controversial. There are no randomized data in humans, and prior animal studies studied time from experimental manipulation, not from the onset of clinical features of sepsis. Using a recently developed murine cecal ligation and puncture model that precisely monitors physiologic deterioration, we hypothesize that incremental hourly delays in the first dose of antibiotics, in the first bolus of fluid resuscitation, or a combination of the two at a clinically relevant point of physiologic deterioration during polymicrobial sepsis will shorten survival. Randomized laboratory animal experimental trial. University basic science laboratory. Male C57BL/6J, female C57BL/6J, aged (40-50 wk old) male C57BL/6J, and BALB/C mice. Mice (n = 200) underwent biotelemetry-enhanced cecal ligation and puncture and were randomized after meeting validated criteria for acute physiologic deterioration. Treatment groups consisted of a single dose of imipenem/cilastatin, a single bolus of 30 mL/kg fluid resuscitation, or a combination of the two. Mice were allocated to receive treatment at the time of meeting deterioration criteria, after a 2-hour delay or after a 4-hour delay. Hourly delays in the initiation of antibiotic therapy led to progressively shortened survival in our model (p < 0.001). The addition of fluid resuscitation was unable to rescue animals, which received treatment 4 hours after meeting enrollment criteria. Systemic inflammation was increased, and host physiology was increasingly deranged with hourly delays to antibiotics. We conclude that antibiotic therapy is highly time sensitive, and efforts should be made to deliver this critical therapy as early as possible in sepsis, perhaps extending into the first point of medical contact outside the hospital.

The Role of Primary Care Physician in Geriatric Care

General practice is the first point of medical contact for patients with the health issues and is a key component of primary care. Primary care provides continuing and comprehensive health care for the individual and not only treats the patient when they are ill, but works with the patient when they are healthy to establish strong health maintenance skills by practicing disease prevention and health education. Geriatric population is a rapidly growing worldwide; this rise of the aging population has had an impact on the practice of medicine (Jamison DT, Sandbu ME, 2001). Clinical practice in primary care focuses on the unique needs of the geriatric population which is different from other patient population. The aged body is different physiologically from the younger adult body, older patients tend to develop a more severe disease state and have co-morbidities leading to longer lengths of stay in the hospital (Zafar SN, Ganatra HA, Tehseen S, Qidwai W, 2006). The chronic non communicable disease and risk for falling increases in the older population, resulting in an increase in serious outcomes and associated health care costs (Graham Ellis, Martin A Whitehead, 2011).

Management of transient ischemic attacks diagnosed by early-career general practitioners: A cross-sectional study.

Background Transient ischemic attack incurs a risk of recurrent stroke that can be dramatically reduced by urgent guideline-recommended management at the point of first medical contact. Aims This study describes the prevalence and associations of new transient ischemic attack presentations to general practice registrars and the management undertaken. Methods A cross-sectional analysis of the Registrar Clinical Encounters in Training cohort study. General practice registrars from five Australian states (urban to very remote practices) collected data on 60 consecutive patient encounters during each of their three six-month training terms. The proportion of problems managed being new transient ischemic attacks and proportion of transient ischemic attacks with guideline-recommended management were calculated. Univariate and multivariable logistic regression established associations of patient, registrar, and practice factors with a problem being a new transient ischemic attack. Results A total 1331 general practice registrars contributed data (response rate 95.8%). Of the 250,625 problems, there were 65 new transient ischemic attacks diagnosed (0.03% [95% confidence interval: 0.02-0.03%]). General practice registrars were more likely to seek help, generate learning goals, and spend more time for a new transient ischemic attack compared to other problems. Compliance with management guidelines was modest: 15.4% ordered brain and arterial imaging, 36.9% prescribed antiplatelet medication, and 3.1% prescribed antihypertensive medication. Conclusions Transient ischemic attack is a very infrequent presentation for general practice registrars, giving little clinical opportunity to reinforce training program education regarding guideline-recommended management. General practice registrars found transient ischemic attacks challenging and management was not ideal. Since most transient ischemic attacks first present to general practice and urgent management is essential, an enhanced model of care utilizing rapid access to specialist transient ischemic attack support and follow-up could improve guideline compliance.

The Potential Role for Early Biomarker Testing as Part of a Modern, Multidisciplinary Approach to Sjögren's Syndrome Diagnosis.

Sjögren's syndrome (SS) is a chronic and progressive multisystem autoimmune disease typically managed by rheumatologists. Diagnostic delays are common, due in large part to the non-specific and variable nature of SS symptoms and the slow progression of disease. The hallmark characteristics of SS are dry eye and dry mouth, but there are a broad range of other possible symptoms such as joint and muscle pain, skin rashes, chronic dry cough, vaginal dryness, extremity numbness or tingling, and disabling fatigue. Given that dry eye and dry mouth are typically the earliest presenting complaints, eye care clinicians and dental professionals are often the first point of medical contact and can provide critical collaboration with rheumatologists to facilitate both timely diagnosis and ongoing care of patients with SS. Current diagnostic criteria advocated by the American College of Rheumatology are predicated on the presence of signs/symptoms suggestive of SS along with at least two objective factors such as traditional biomarker positivity, salivary gland biopsy findings, and/or presence of keratoconjunctivitis sicca. Traditional biomarkers for SS include the autoantibodies anti-Sjögren's syndrome-related antigen A (SS-A/Ro), anti-Sjögren's syndrome-related antigen B (SS-B/La), antinuclear antibody (ANA) titers, and rheumatoid factor (RF). While diagnostically useful, these biomarkers have low specificity for SS and are not always positive, especially in early cases of SS. Several newly-identified biomarkers for SS include autoantibodies to proteins specific to the salivary and lacrimal glands [SP-1 (salivary gland protein-1), PSP (parotid secretory protein), CA-6 (carbonic anhydrase VI)]. Data suggest that these novel biomarkers may appear earlier in the course of disease and are often identified in cases that test negative to traditional biomarkers. The Sjö® test is a commercially available diagnostic panel that incorporates testing for traditional SS biomarkers (anti-SS-A/Ro, anti-SS-B/La, ANA, and RF), as well as three novel, proprietary early biomarkers (antibodies to SP-1, PSP, and CA-6) which provide greater sensitivity and specificity than traditional biomarker testing alone. Timely diagnosis of SS requires appropriate clinical vigilance for potential SS symptoms, referral and collaborative communication among rheumatology, ophthalmology, and oral care professions, and proactive differential work-up that includes both physical and laboratory evaluations.

Telecardiology: clinical, technical and social aspects. The project of the ASP of Cosenza, Italy

The aim of this paper is to present the project of telecardiology within the ASP of Cosenza, one of the largest provinces of Italy characterized by a particular orography, with difficult and inaccessible roads. The goal of this project is to manage the emergency more efficiently by reducing the time of intervention by bringing the patient not to the nearest hospital, but more importantly to the hospital more appropriately suited to better manage the cardiological emergency. This system also uses the most modern web-based interface technology protected by login and password. The project also provides the integration, supply and installation of advanced and modern central by ensuring efficient screening is carried out using monitors in all the coronary care units of the ASP of Cosenza, networking with electrocardiography of all the point of first medical contact and all the 118 emergency rescue service. By integrating all these procedures and information and making them available to any point in the hospital and territorial network, this project becomes not only a more efficient system for managing cardiac emergency but also a pathway that will guarantee increased care of patients from the onset of symptoms to discharge.

Evidence for a delay in diagnosis of Wilms’ tumour in the UK compared with Germany: implications for primary care for children

The UK has a longstanding system of general practice which provides the vast majority of primary care, including that for children. It acts as a 'gatekeeper' to more specialist care....

Gebelikte El-Ayak-Ağız Hastalığı: Olgu Sunumu

The prevalence of hand, foot and mouth disease caused by the Enterovirus family has been increasing in our country in the recent years mainly among children, but also among adults. The disease is often observed in primary care that is the first point of medical contact with the patients and is focused on preventive medicine. In this study, we intended to call attention to this disease by a pregnant case.

Repenser la place des soins de santé primaires en France – Le rôle de la médecine générale

Primary healthcare is poorly structured in France while it is well defined at the international level: it is the point of first medical contact of the population with the healthcare system. General practice is the clinical specialty oriented to primary healthcare. Data in the scientific literature highlight the need of refocusing the health system on primary care known to improve both morbi-mortality and care efficiency. In France, health authorities acknowledge general practitioners as playing a key role in the health care system: its time to move from intention to action. Structural changes are needed to achieve this reinforcement of primary healthcare: to re-orientate medical studies towards primary care; to develop research in primary care; to promote cooperation between care providers; to ease the daily workload of practitioners; to diversify methods of payment; to propose a guide for patient's use of primary care. The transformation of the healthcare system in France requires a real strategy of primary healthcare implementation. Regardless of financial constraints, it is possible to redistribute the resources towards ambulatory care. Strengthening the role of general practice and favoring its societal recognition will be the major stages of this change.