Primary Care Centers Research Articles

1939-LB: Improving Capacity for Quality Improvement in Type 2 Diabetes Primary Care Centers

1939-LB: Improving Capacity for Quality Improvement in Type 2 Diabetes Primary Care Centers

Expert system-based application for fatal ventricular arrhythmia risk level estimation based on QT-Interval prolongation

There is an overwhelming number of medications that can affect the morphology of the beating heart by delaying the ventricular depolarization and repolarization processes, resulting in an elongated QT interval. This circumstance, in turn, can lead to ventricular arrhythmias, which can result in the patient’s death, as was overwhelmingly the case at the beginning of the coronavirus pandemic. In this regard, this document presents an innovative expert system-based application devoted to estimating the level of risk of fatal ventricular arrhythmia as a consequence of QT prolonging treatments. For this purpose, the use of a fuzzy rule-based system has been considered for the decision-making process, establishing three different risk levels regarding the QT interval obtained from an electrocardiogram, its evolution from a basal electrocardiogram, and other significant clinical information of the patient such as age, sex, among others. This novel expert system-based application has been designed by considering the criteria of several specialist physicians from four different Spanish private and public hospitals. The proposed application can be especially important in primary health care centers, where the absence of specialists is remarkable because it provides clinical staff with a powerful tool for estimating the level of risk of fatal ventricular arrhythmia with 96.5% accuracy when comparing its decisions to those of specialist physicians, which could imply a significant reduction in the risk of death due to fatal ventricular arrhythmias in patients with QT prolonging treatment. In this respect, the developed application is currently used in some primary health care centers in Spain.

Evaluation of the Nurses' Understanding of Disease Prevention and Health Promotion in Primary Health Care Centres in Al-Diwaniyah

A descriptive study was undertaken from January 15, 2023 to May 26, 2023 in order to measure the level of knowledge among nurses This text pertains to the improvement of health and the avoidance of illnesses at primary healthcare clinics located in the municipality of Al-Diwaniyah. A precise random population of 150 individuals, evenly distributed among There are eleven primary health care institutions located in the city of Al Diwaniyah. The numbers were obtained from the health promotion and disease prevention tool that has been authorized by the Iraqi Ministry of Health. Data was gathered by conducting a questionnaire for each variable, employing a research instrument and the personal interview method. Each survey necessitated roughly 10 minutes to complete. The questionnaire comprised four axes, with the initial axis explicitly focusing on community partnership and mobilization. The second axis relates to the local council of the primary health care centre. The third level of communication focuses on modifying behaviour, while the fourth dimension revolves around promoting health and preventing sickness. The data was evaluated using the weighted average method, renowned for its ability to generate accurate outcomes by using the principle of weight ratios. The study found that the research sample had outstanding expertise in the field of health promotion and illness prevention. The study proposes improving training programs in primary health care, with a specific emphasis on boosting communication skills and promoting changes in health behaviours. Additionally, it suggests prioritizing community involvement and activation, while also strengthening the local governing bodies of basic healthcare facilities. In addition, the study cautions against indiscriminately replacing experienced nurses with new workers.

An Analysis of Referrals Done by Primary Care Centers to Tertiary Care Institutions.

Background and aim Primary care is an important element for every healthcare system around the world. Providing and optimizing the connection between the primary care centers and advanced clinical centers is a key concept for a well-functioning healthcare system. Our aim in this study was to analyze and review the referral data of primary care centers located in Ankara, Türkiye. Materials and methods We collected the entire referral data from the primary care centers, totaling 8,746 patients between January 1, 2019 and December 31, 2023 by using emergency medical services (EMS) transfer in Ankara. Demographic data, call reasons, transfer centers and transfer-related characteristics of the patients were recorded retrospectively, grouped by year, using EMS data. Results Our findings have shown that most of the referrals were made for Turkish citizens with 8,360 (95.6%) (p<0.001). Healthcare centers located in inner city had the most referrals made with 7,087 (81.0%) (p<0.001). Majority of the referrals were made by physicians in family healthcare centers with 6,583 (75.3%) (p<0.001) with chest pain being the most common diagnosis for referral initiation with 1,429 (16.3%) (p<0.001). This was followed by trauma, with 1,172 (13.4%) (p<0.001). Most common cause for trauma was falls with 613 (52.3%) (p<0.001). Conclusion Our data revealed important elements of local referral patterns. According to our data, majority of the referrals were made by inner city healthcare facilities. Family healthcare centers formed most of the referral requests. For this reason, strengthening these centers is important to prevent unnecessary resource use and delays.

Postpartum family planning among women attending maternal and child health centers in Assiut Governorate, Upper Egypt

BackgroundPostpartum family planning (PPFP) is important in helping couples to achieve their reproductive intentions. National surveys have consistently reported higher fertility, lower use of family planning (FP), and higher unmet needs for FP in Upper Egypt. This study aims to identify the factors associated with the use of PPFP in Assiut Governorate, Upper Egypt, and to assess the current status of integration of PPFP counseling in the existing maternal and child health services (MCH).MethodsThe study employed a cross-sectional study design, collecting data from 455 postpartum women aged 15 to 49 years in 4 primary health care (PHC) centers in Assiut Governorate, Upper Egypt. The women were interviewed using a structured questionnaire. The questionnaire consisted of 4 sections: the first section included the participants’ demographic characteristics; the second section included women’s obstetric history; the third section included questions about PPFP knowledge, attitude, past and current use of contraception; and the fourth section assessed the current status of integrating PPFP counseling within antenatal, natal, and postnatal services.ResultsIn total, 54.5% of postpartum women were using a modern contraceptive method. The significant predictors of using PPFP methods were as follows: receiving information about PPFP from health care providers (AOR = 11.46, p < 0.001), better attitude towards PPFP (AOR = 10.54, p < 0.001), using modern FP methods (AOR = 6.98, p < 0.001), resumption of menstruation (AOR = 4.11, p < 0.001), older age (AOR = 2.15, p < 0.05), and better PPFP knowledge (AOR = 1.72, p < 0.001). Only 5.3%, 1.3%, and 3.5% received PPFP counseling during antenatal care (ANC), delivery, and the postpartum period, respectively.ConclusionsPostpartum contraception use was associated with receiving PPFP counseling by health care providers and women’s knowledge and attitude regarding PPFP. However, FP counseling was not integrated with other MCH services. Updating the components of MCH services to include PPFP counseling during ANC, at delivery, and during the postpartum period should be prioritized by program planners and policymakers.

Combined Robotic and Vaginal Surgery for Pelvic Exenteration Due to Vaginal Sarcoma Relapse in an Obese Woman

Pelvic exenteration (PE) is an aggressive surgical procedure that implies a large hard-to-fill pelvic defect. Different reconstruction techniques were proposed to improve abdominal organ support and reduce complications (infections, pelvic organs herniation, vaginal stump dehiscence, bowel prolapse and obstruction) [1], with conflicting results [2]. Because of young age and survival greater than 50% at 5 years in patients with no residual tumor after surgery [3], a new approach with better clinical results to pelvic reconstruction is needed. The aim of this surgical film is to present an unusual presentation of vaginal sarcoma, successfully managed with a minimally invasive approach, and to illustrate our contextual multilayer technique of pelvic reconstruction using a combination of pedicled omental flap (POF) and human acellular dermal matrix (HADM). Tertiary level academic hospital. A 42-year-old obese patient with recurrent and symptomatic myxoid leiomyosarcoma, previously underwent vaginal-assisted laparoscopic surgery at a primary care center for the removal of a vaginal swelling. The multidisciplinary board determined anterior PE as the optimal therapeutic approach. Given the patient's body mass index (33 kg/m2), young age, and the favorable outcomes of robotic surgery in obese patients compared with other approaches [3,4], we proposed a combined robotic and vaginal surgery for both exenteration and reconstructive procedures [5]. During surgery, we initially explored the abdominal cavity to exclude macroscopic metastasis, followed by anterior PE. Urinary diversion was achieved with a Bricker ileal conduit by means of an ileoileal laterolateral anastomosis and an uretero-ileo-cutaneostomy. The pelvic dead space was partially filled with a POF on the left gastroepiploic artery. Subsequently, the pelvic defect was covered by a 15 × 10 mm HADM inlay inserted circumferentially at the pelvic brim, fixed with a barbed thread suture on residual pelvic structures. The final pathology confirmed the recurrence of myxoid leiomyosarcoma and indicated tumor-free resection margins. The intraoperative and postoperative periods were uneventful. The patient was discharged 14 days after surgery and underwent adjuvant doxorubicin- and dacarbazine-based chemotherapy, which was initiated 45 days after the surgery. Currently the patient is asymptomatic and disease free at the sixth month of follow-up. Robotic PE proves to be a feasible technique in obese patients, reducing postoperative hospital stay and complications. The contextual pelvic floor reconstruction with a POF and HADM supports abdominal viscera, diminishing interorgan adhesions and bowel prolapse. VIDEO ABSTRACT.

Lifestyle counseling in patients with hypertension in primary health care and its association with antihypertensive pharmacotherapy.

The study aimed to investigate differences in hypertensive- and cardio-preventive pharmacotherapy depending on if patients with hypertension received lifestyle counseling or not, including the difference between men and women. Data from the Region Stockholm VAL database was used to identify all patients with a hypertension diagnosis and had visited a primary health care center within the past five years. Data included registered diagnoses, pharmacotherapy, and codes for lifestyle counseling. Logistic regression adjusted for age and comorbidity (diabetes, stroke, coronary heart disease, atrial fibrillation, gout, obesity, heart failure) was used, presenting results as odds ratios (OR) with 99% confidence interval (CI). The study included 130,030 patients with hypertension; 63,402 men and 66,628 women. Patients receiving recommended lifestyle counseling were more frequently treated with three or more hypertensive drugs: women OR 1.38 (1.31, 1.45) and men=1.36 (1.30, 1.43); certain drug classes: calcium antagonists: women 1.09 (1.04, 1.14) and men 1.11 (1.06, 1.16); thiazide diuretics: women 1.26 (1.20, 1.34) and men 1.25 (1.19, 1.32); and aldosterone antagonists: women 1.25 (1.12, 1.41) and men 1.49 (1.34, 1.65). Patients receiving recommended level of lifestyle counseling with concomitant coronary heart disease, atrial fibrillation, diabetes, or stroke were more frequently treated with statins than those who did not. Further, recommended lifestyle counseling was significantly associated with anticoagulant treatment in patients with atrial fibrillation. Lifestyle counseling according to recommendations in national guidelines was significantly associated with a more thorough pharmacological treatment of hypertension, statins, and antithrombotic drugs as well as anticoagulants, in both men and women.

Study protocol for a pilot quasi-experimental study on oral health education for nurses and community health workers in Nigeria.

The primary health care system provides an ideal setting for the integration of oral health into general health care as well as equitable access to oral health care. However, the limited oral health knowledge of primary health care workers necessitates appropriate training before they can participate in health promotion efforts. This pilot training was designed to examine the impact of the Oral Health Education module for Nurses and Community Health Care Workers on their oral health awareness and referral practices. This study will utilize a quasi-experimental design (pre-and post with a non-equivalent control group) to assess the impact of a five-day pilot oral health education program on the knowledge and referral practices of Nurses and Community Health Workers in primary health care centers in three states in Nigeria-(Lagos, Oyo, and Kano). The training modules were developed based on the six iterative steps described in the intervention mapping framework - needs assessment, highlighting program objectives and outcomes, selection of theory and mode of intervention, designing program based on theory, designing implementation plans, and developing an evaluation plan. Only the intervention group will participate in the full educational training sessions but both groups will complete the pre-and post-intervention questionnaires. This pilot training combined the standardized training modules from the recently launched "Oral Health Training Course for Community Health Workers in Africa" and a newly developed maternal and child oral health module by our group using an evidence-based approach. To the best of our knowledge, this is the first program to examine the impact of the standardized OpenWHO modules. The success of this training will lay the foundation for developing a sustained channel for providing oral health education at the primary health care level in Nigeria, West Africa, and Africa.

Office measurement vs. ambulatory blood pressure monitoring: associations with mortality in patients with or without diabetes.

Guidelines suggest similar blood pressure (BP) targets in patients with and without diabetes and recommend ambulatory BP monitoring (ABPM) to diagnose and classify hypertension. It was explored whether different levels of ambulatory and office BP and different hypertension phenotypes associate with differences of risk in diabetes and no diabetes. This analysis assessed outcome data from the Spanish ABPM Registry in 59 124 patients with complete available data. The associations between office, mean, daytime, and nighttime ambulatory BP with the risk in patients with or without diabetes were explored. The effects of diabetes on mortality in different hypertension phenotypes, i.e. sustained hypertension, white-coat hypertension, and masked hypertension, compared with normotension were studied. Analyses were done with Cox regression analyses and adjusted for demographic and clinical confounders. A total of 59 124 patients were recruited from 223 primary care centres in Spain. The majority had an office systolic BP >140 mmHg (36 700 patients), and 23 128 (40.6%) patients were untreated. Diabetes was diagnosed in 11 391 patients (19.2%). Concomitant cardiovascular (CV) disease was present in 2521 patients (23.1%) with diabetes and 4616 (10.0%) without diabetes. Twenty-four-hour mean, daytime, and nighttime ambulatory BP were associated with increased risk in diabetes and no diabetes, while in office BP, there was no clear association with no differences with and without diabetes. While the relative association of BP to CV death risk was similar in diabetes compared with no diabetes (mean interaction P = .80, daytime interaction P = .97, and nighttime interaction P = .32), increased event rates occurred in diabetes for all ABPM parameters for CV death and all-cause death. White-coat hypertension was not associated with risk for CV death (hazard ratio 0.86; 95% confidence interval 0.72-1.03) and slightly reduced risk for all-cause death in no diabetes (hazard ratio 0.89; confidence interval 0.81-0.98) but without significant interaction between diabetes and no diabetes. Sustained hypertension and masked hypertension in diabetes and no diabetes were associated with even higher risk. There were no significant interactions in hypertensive phenotypes between diabetes and no diabetes and CV death risk (interaction P = .26), while some interaction was present for all-cause death (interaction P = .043) and non-CV death (interaction P = .053). Diabetes increased the risk for all-cause death, CV, and non-CV death at every level of office and ambulatory BP. Masked and sustained hypertension confer to the highest risk, while white-coat hypertension appears grossly neutral without interaction of relative risk between diabetes and no diabetes. These results support recommendations of international guidelines for strict BP control and using ABPM for classification and assessment of risk and control of hypertension, particularly in patients with diabetes. Not applicable.

SARS-CoV-2 detection in aerosol from community indoor environments

Since its emergence, the COVID-19 pandemic has profoundly and extensively affected global health and society. Numerous studies have focused on detecting SARS-CoV-2 in air samples collected in healthcare indoor spaces, but few have analysed its presence in air samples from other public community spaces. In addition, limited studies have surveyed indoor spaces where it was not known if individuals with COVID-19 were present or had been present at the time of sampling. This study aimed to determine the SARS-CoV-2 genetic load in aerosol samples collected in public community indoor environments where prior knowledge of the presence of infected individuals with COVID-19 cases is not available at the time of sampling.Air samples (N = 497) were collected from healthcare settings, elderly care homes, and educational settings in the Valencian Community, Spain. RNA was extracted and the N1, N2, and E gene fragments of SARS-CoV-2 were quantified using RT-qPCR. SARS-CoV-2 RNA was detected in 8.9 % of air samples. The highest positivity rates were observed in hospitals (16.2 %), elderly care homes (15.3 %), and primary care centres (12.7 %). Concentration of the N1 gene in positive samples ranged 4.3–504 gc/m3 (n = 10), 6.2–77 gc/m3 (n = 8) and 5.1–14 gc/m3 (n = 7), respectively. The genes N2 and E were less frequently detected and generally reported lower concentrations.The frequency of detection of SARS-CoV-2 in aerosols increased at the same time that the population COVID-19 cumulative incidence increased.

Infant Feeding Pattern during the First Six Months of Age among Primipara Mothers

The exclusive breastfeeding (EBF) rates are low globally and in Saudi Arabia. This study aimed to identify the type of infant feeding practiced during the first six months of age and determine if there is an association between demographic characteristics and the type of breastfeeding. A descriptive cross-sectional survey was conducted on 401 primipara mothers who attended 15 primary health care centers (PHCCs)by using a self-administered questionnaire. Only 17.2% of infants were exclusively breastfed, and 65.8% were given mixed feeding in the first six months of life. The breastfeeding rate declined from 99.8% in the first month to 76.3% by six months, with a corresponding increase in the use of formula milk, plain water and dates from 31.7%, 24.9%, and 24.7% in the first month to 53.1%. 49.1%, and 32.7% in the six months, respectively. Mothers also used herbs, lump sugar, glucose water and honey every month. A chi-square test reveals no association between the demographic characteristics and type of breastfeeding (EBF, predominant breastfeeding and mixed feeding). The primipara mothers had low EBF rates indicating the need to provide culture-specific education, support and counselling.

Neurotoxicity and acute oxalate nephropathy in a Chronic kidney disease patient due to plant toxin (Bilimbi fruit -Averrhoabilimbi) : case report from a primary care center of Bangladesh

Neurotoxicity and acute oxalate nephropathy in a Chronic kidney disease patient due to plant toxin (Bilimbi fruit -Averrhoabilimbi) : case report from a primary care center of Bangladesh

Psychometric Testing of the Thai Version of Self-Care of Chronic Illness Inventory Version 4c in Patients With Stroke.

Self-Care of Chronic Illness Inventory version 4c is a non-disease-specific self-care measure used in individuals with multiple chronic conditions. This instrument may be applied to patients with specific diseases such as stroke. The aim of this study was to evaluate the psychometric properties of the Thai version of the Self-Care of Chronic Illness Inventory version 4c in patients with stroke. This multicenter, cross-sectional study adhered to the COSMIN (Consensus-based Standards for the Selection of Health Measurement Instruments) guidelines and enrolled patients with stroke from 16 primary care centers in southern Thailand. Structural validity was assessed using confirmatory factor analysis, internal consistency reliability using Cronbach α coefficient and global reliability index, and test-retest reliability using intraclass correlation coefficients. The final analysis included a total of 350 participants. Confirmatory factor analysis supported the 2-factor Self-Care Maintenance scale structure, although the item allocation to the dimensions differed from that of the original model. The Self-Care Monitoring scale demonstrated a 1-factor structure with permitted residual covariance. The Self-Care Management scale maintained a 2-factor structure, similar to that of the original model. Simultaneous confirmatory factor analysis of the combined items supported the general model with the 3 scales. The Self-Care Maintenance scale exhibited marginally adequate α (0.68) and ω (0.66) coefficients, and an adequate composite reliability index (0.79). The other 2 scales demonstrated adequate α (range, 0.79-0.86), ω (range, 0.75-0.86), and composite reliability (range, 0.83-0.86) indices. Intraclass correlation coefficients showed adequate test-retest reliability for all scales (range, 0.76-0.90). The generic self-care measure, Self-Care of Chronic Illness Inventory version 4c, demonstrated strong psychometric properties in patients with stroke. This instrument may be a valuable tool for assessing stroke self-care in Thailand.

HIV screening guidance - ignored or forgotten?

NICE guidance states new patients aged 15-59 registering at a primary care centre in a high-risk area for HIV, should be offered testing. First, this allows for prompt initiation of antiretroviral therapy, improving the individual's morbidity and mortality while reducing community transmission. Second, increasing the breadth of the population offered tests would help normalise testing, reducing stigma and increasing uptake. AIM: To retrospectively audit adherence to HIV testing guidance in new patients registering at a GP in Walsall, where HIV risk is categorised as high, and to make recommendations based on the results. The EMIS records of 310 new patients aged 15-59 who registered during a 12-month period (October 2021 to October 2022) were accessed to establish if they were offered HIV testing. A survey was created and distributed to staff in the practice to understand the reason for lack of testing. The audit revealed that none of the 310 patients were offered an HIV test. The survey indicated that 75% of staff members were unaware of the guideline, 66.7% never ordered an HIV test, and 83% stated that they do not believe GPs are given enough support to follow guidelines. The guidance for screening for HIV in this primary care centre is therefore not followed due to a lack of awareness of the guideline and HIV risk in the area. We recommend that this audit is conducted across more primary care centres in HIV high-risk areas to assess if this outcome is representative of general adherence to guidance.

Integrating Syrian refugees into Lebanon’s healthcare system 2011–2022: a mixed-method study

IntroductionThe Lebanese government estimates the number of Syrian refugees to be 1.5 million, representing 25% of the population. Refugee healthcare services have been integrated into the existing Lebanese health system. This study aims to describe the integration of Syrian refugee health services into the Lebanese national health system from 2011 to 2022, amid an ongoing economic crisis since 2019 and the COVID-19 pandemic.MethodsThis paper employs a mixed-methods approach drawing upon different data sources including: 1- document review (policies, legislation, laws, etc.); 2- semi-structured interviews with policymakers, stakeholders, and health workers; 3- focus group discussions with patients from both host and refugee populations; and 4- health systems and care seeking indicators.ResultsAlthough the demand for primary health care increased due to the Syrian refugee crisis, the provision of primary health care services was maintained. The infusion of international funding over time allowed primary health care centers to expand their resources to accommodate increased demand. The oversupply of physicians in Lebanon allowed the system to maintain a relatively high density of physicians even after the massive influx of refugees. The highly privatized, fragmented and expensive healthcare system has impeded Syrian refugees’ access to secondary and tertiary healthcare services. The economic crisis further exacerbated limits on access for both the host and refugee populations and caused tension between the two populations. Our findings showed that the funds are not channeled through the government, fragmentation across multiple financing sources and reliance on international funding. Common medications and vaccines were available in the public system for both refugee and host communities and were reported to be affordable. The economic crisis hindered both communities’ access to medications due to shortages and dramatic price increases.ConclusionIntegrating refugees in national health systems is essential to achieve sustainable development goals, in particular universal health coverage. Although it can strengthen the capacity of national health systems, the integration of refugees in low-resource settings can be challenging due to existing health system arrangements (e.g., heavily privatized care, curative-oriented, high out-of-pocket, fragmentation across multiple financing sources, and system vulnerability to economic shocks).

Implementation of a Comprehensive and Personalised Approach for Older People with Psychosocial Frailty in Valencia (Spain): Study Protocol for a Pre-Post Controlled Trial.

With ageing, the risk of frailty increases, becoming a common condition that exposes older people to an increased risk of multiple adverse health outcomes. In Valencia (Spain), the ValueCare project develops and applies a value-based care approach that addresses the multidimensional nature of frailty by implementing integrated and personalized care to tackle psychosocial frailty. A pre-post controlled design with a baseline measurement at inclusion, at the end of implementation and a follow-up measurement after 6 months of intervention. In Valencia (Spain), 120 participants over 65 years of age are recruited from primary care centres to receive the ValueCare comprehensive and personalised care plan according to the results and are compared with 120 participants receiving "usual care". An assessment questionnaire is designed using validated instruments, and a personalised care plan is developed specifically for each participant based on the results obtained. The study protocol has been registered under the ISRCTN registration number ISRCTN25089186. Addressing frailty as a multidimensional and multifactorial risk condition requires the development and implementation of comprehensive assessments and care. In this context, this study will provide new insights into the feasibility and effectiveness of a value-based methodology for integrated care supported by ICT for older people experiencing frailty.

Person-centred care and the work-related health and job satisfaction of health and social care professionals: protocol for a prospective longitudinal cohort study combined with qualitative studies (the PCC@Work project)

BackgroundThe interplay of ethical stress, heavy workloads, and job dissatisfaction poses challenges to both the recruitment and retention of health and social care professionals. Person-centred care, rooted in ethical principles, involves collaborative care, and is expected to improve care and job satisfaction. However, prior research on the impact of person-centred care practices on professionals’ work-related health and job satisfaction has yielded mixed results, and most studies emanate from residential care. Understanding how person-centred care practices influence health and social care professionals across different care settings thus requires further exploration through rigorous methodology. The overall aim of PCC@Work is to follow, describe, assess, and explore the impact of person-centred care practices in hospital wards, primary care centres and municipal care on health and social care professionals’ work-related health and job satisfaction.MethodsPCC@Work is designed as a prospective, longitudinal cohort study combined with qualitative studies. A web-based questionnaire will be distributed on five occasions within two years to health and social care professionals in the three care settings. In addition, focus groups and interviews will be conducted with a selection of health and social care professionals to explore their experiences of work-related health and job satisfaction in relation to person-centred practices.DiscussionPCC@Work will highlight some of the knowledge gaps on the impact of person-centred care practices regarding work-related health and job satisfaction of health and social care professionals. The uniqueness of the project lies in the multi-method design, combining a prospective longitudinal cohort study with qualitative studies, and the involvement of various professions and settings. This means we will be able to provide a comprehensive and representative understanding of person-centred care practices as a critical component for effective change in the working conditions of health and social care.

Fistula of the mitral-aortic intervalvular fibrosa in a patient with bacterial endocarditis: a case report and systematic literature review

SummaryBackgroundA fistulous tract in the mitro-aortic intervalvular fibrosa (MAIVF) is a rare entity, which presents as a complication of endocarditis or surgical trauma. Generally, it is associated to a pseudoaneurysm of the MAIVF (p-MAIVF) or aortic abscesses. MAIVF fistulas could potentially lead to devastating complications and a high mortality rate. This condition is managed surgically, either by a percutaneous closure or an open surgical approach. Herein we report the complex case of a patient with a MAIVF fistula secondary to bacterial endocarditis. Further clinical deterioration was caused by severe aortic valve insufficiency and hemodynamic compromise, requiring surgical intervention.Case presentationA 74-year-old male patient was admitted to a primary care center with complaints of malaise, asthenia, adynamia, hyporexia, and lower limb edema over the past eight days. His past medical history is positive for arterial hypertension and being monorenal. A transesophageal echocardiogram (TEE) was performed, exhibiting a 56% left ventricle ejection fraction (LVEF) and complicated aortic valve endocarditis. Surgical management through an open approach included vegetation resection, valve replacement, and closure of the MAIVF fistula. After completing antibiotic therapy, the patient was discharged without complications. During postoperative follow-up, the patient remained asymptomatic, and the control echocardiogram showed no signs of MAIVF fistula.4.ConclusionsThe clinical case of a patient with a MAIVF fistula secondary to endocarditis by Streptococcus Anginous was presented. The fistulous tract was not associated to p-MAIVF or aortic abscess, findings which further deteriorate the patient’s condition and increase the likelihood of fatality. This case reinforces the importance of a prompt diagnosis through cardiac imaging and timely surgical closure of the defect.

Adequacy of Antenatal Care at Ministry of Health Facilities in Jeddah, Saudi Arabia: A Cross-Sectional Study.

Background Most pregnancy-related complications and undesirable outcomes are preventable by effective interventions at a reasonable cost. These interventions are mainly deployed during the antenatal phase and are included under the umbrella of antenatal care (ANC). To our knowledge, no studies have been conducted to assess the adequacy of ANC in Saudi Arabia. This study aimed to measure and quantify the adequacy of ANC provided by the Ministry of Health (MoH) facilities in Jeddah and to determine potential factors influencing ANC. Methodology In this cross-sectional study, we used the Adequacy of Perinatal Care Utilization index to measure the adequacy of ANC. Data were collected from September 2023 to March 2024 in two randomly selected MoH hospitals by interviewing mothers and collecting data from medical records. Results A total of 303 mothers participated in this study. Mothers' mean age was 31 years, and 50% of them had received higher school education. Prevalence of adequate ANC was 64.7%. There was a significant association between the adequacy of ANC and mothers' level of education (p < 0.001), time taken to reach the nearest primary care center (p < 0.001), number of total pregnancies (p < 0.034), and the total number prenatal visits (p < 0.001). Conclusions This is the first study to shed light on the prevalence of adequacy of ANC in Saudi Arabia and its associated factors. This study would pave the way to investigate the adequacy of ANC on a national level and will aid policymakers in developing and implementing effective ANC preventive measures, hence helping improve women's health and their babies.

#3014 Primary care perspective on management of chronic kidney disease in Tunisia

Abstract Background and Aims Chronic Kidney Disease (CKD) represents a significant public health challenge. The primary care physician holds a crucial position in facilitating its early detection, serving as a linchpin in the comprehensive management of patients often with multiple comorbidities. The objective of our study was to investigate CKD management in primary care practitioners in Tunisia and their relationship with nephrologists. Method We conducted a cross-sectional study involving family physicians and general practitioners. This involved a self-administered questionnaire using Google Forms, aiming to investigate CKD management in the context of primary care in Tunisia, along with an examination of collaboration with nephrologists. Results Our study included 43 practitioners with a gender ratio of M/F = 0.3. The average age of participants was 30.7 years [25-53 years]. Of the 43 participants, 95% practiced in urban areas, and 74% were in training. They worked in university hospitals (53%), primary care centers (21%), regional hospitals (19%), and private practices (7%). When asked about their feelings during the management of a patient with CKD, the main response was anxiety (65%) followed by indifference (18%), confidence (12%), and fear (5%). According to practitioners, the uniqueness of CKD management was due to the polypathological nature of patients (79%), the difficulty in managing certain cases (74%), the difficulty in applying certain recommendations (60%), the lack of medications (2%), and the difficulty in accessing complementary tests in primary care (2%). The means of training and sources of information on CKD mentioned were specialized medical journals (49%), medical websites (40%), peer groups (4%), pharmaceutical industry representatives (2%), and no source (5%). The means of training included additional studies certificates (23%), workshops/plenary sessions (44%), specialized webinars (30%), intra-hospital medical days (46%), nephrology internships (28%), and no available means (16%). Regarding the relationship with the nephrologist in joint management, 42% had a corresponding nephrologist. Thirty percent declared no difficulty in referring patients to nephrology when necessary. In case of difficulty, it would be related to long delays in obtaining a consultation with the nephrologist (60%), the geographical distance of nephrology centers (30%), and sometimes patient refusal (23%). When discovering CKD, 60% immediately referred patients to the nephrologist. On a scale of 0 to 5, communication and coordination of care between nephrologists and primary care physicians were estimated at 0 by 12%, 1 by 16%, 2 by 30%, 3 by 30%, 4 by 12%. Regarding end stage CKD management, practitioners informed patients about kidney transplantation (9%), hemodialysis (53%), peritoneal dialysis (16%), and 55% stated they did not have to inform patients about these techniques. Sixty-three percent continued to follow patients after the initiation of renal replacement therapy. Conclusion Our work revealed that the predominant sentiment when dealing with CKD patients in primary care is anxiety. This emotion appears to stem from the intricate nature of CKD management, primarily associated with the polypathological profile of patients and challenges in implementing recommended guidelines, compounded by difficulties in accessing nephrologist consultations. The imperative challenge lies in enhancing information accessibility for practitioners to optimize CKD management within this medical context.