Focus: Preventive Medicine: Pre-Participation Screening of Athletes: Primary Health Care Physicians’ Knowledge,Experience, and Approach in Turkey

Pre-participation screening (PPS) is crucial for assessing the competitive athletes since their risk of sudden death is higher than non-athletes. In Turkey, PPS is performed at the primary health care setting by primary care physicians (PCPs) who are family medicine specialists (FMSs) or general practitioners (GPs). Although there are national guidelines, there is no legal regulation for this process. This study aims to evaluate PCPs’ knowledge, experience, and approach about PPS. We prepared an online survey for PCPs and used non-probabilistic sampling. PPS attitudes and practices were analyzed and compared according to factors such as experience, education, and being GP or FMS. Of the 214 PCPs included in the study, 39.3% were female. The mean age was 44.9 years (SD:8.88). The average work experience was 7.9 years. Most participants were aware of their authorization to perform PPS (89.7%) and had previously prepared it (90.2%). However, 6.5% of them felt confident in performing PPS. Only 13.1% were aware of the guidelines. Almost 25% of the participants stated being informed about the subject at some part of their career, but this did not affect the confidence or referral decisions. In addition to medical history and physical examination, further testing was considered necessary by 96.3% of the participants. Significantly more tests were ordered by GPs than FMSs (p=0.026 and p=0.011, respectively). The accurate referral decision ratio was 59.3%, without difference between FMSs and GPs (p=0.216). We found that awareness of the guidelines was low among PCPs who lack confidence in PPS. These factors collectively increased the tendency for unnecessary further testing and referral. Therefore, the PPS implementation into medical school and residency curriculums and national legal regulation for the process is a necessity in Turkey.     

儿童重症监护病房医院感染暴发白色念珠菌血流感染4例分析

摘要 目的：探讨儿童重症监护病房白色念珠菌血流感染暴发的临床表现、危险因素、控制措施等,为预防和控制院内白色念珠菌血流感染暴发提供科学依据。方法：以2018年7月我院儿童重症监护病房发生的4例白色念珠菌血流感染暴发患儿为研究对象,分析患儿临床情况、临床特征、危险因素、暴发原因以及采取的预防控制措施。结果：4例医院感染暴发白色念珠菌血流感染患儿均存在基础疾病、有机械通气史、存在中心静脉或动脉置管、静脉或动脉置管前后均使用碘伏消毒、曾使用广谱抗生素、输血制品,白色念珠菌血流感染后最突出的临床表现均是发热。药敏方面,医院感染暴发的4例白色念珠菌感染患儿对唑类及5-氟胞嘧啶均耐药,但对两性霉素B均敏感。经拔除血管置管、减少或者避免广谱抗菌药的应用,根据药敏使用卡泊芬净及两性霉素B抗真菌等积极治疗,1例患儿放弃治疗后死亡,3例患儿顺利出院。通过Fisher确切概率法分析可知,留置中心静脉或动脉置管是儿童重症监护病房发生医院感染暴发白色念珠菌血流感染的危险因素（P<0.05）。结论：留置中心静脉或动脉置管是儿童重症监护病房发生医院感染暴发白色念珠菌血流感染的危险因素,医院感染暴发白色念珠菌血流感染患儿最突出的临床表现是发热,唑类及5-氟胞嘧啶耐药的患儿使用卡泊芬净及两性霉素B可能获得较好的治疗效果。     

中国基层医疗机构手癣和足癣诊治现状调查

目的了解基层医生有关手癣、足癣的诊治现状,分析影响因素,制定有针对性的措施。方法通过网络平台对全国19个省市的基层医生进行问卷调查。结果共回收完整问卷729份。结果显示:①约20%的基层医生对手、足癣的发病因素方面存在认识不足,约50%的基层医生对受侵犯皮肤的组织定位存在误区。②基层医生对手、足癣鉴别诊断的重要性重视不够,真菌镜检设备使用率不足一半。③基层医生能正确选用外用抗真菌药,硝酸咪康唑乳膏使用率超过80%。④仍有10.70%的基层医生推荐使用外用糖皮质激素治疗手、足癣。结论基层医生在手、足癣的规范诊疗方面仍有待提高。     

Better survival after transcatheter aortic valve replacement by process improvements

ObjectiveThe aim of this study is to assess the effects on procedural, 30-day, and 1‑year all-cause mortality by a newly introduced quality improvement strategy in patients after transcatheter aortic valve replacement (TAVR).MethodsIn October 2015, a coherent set of quality improving interventions with respect to patient geriatric screening, general diagnostic examination and safety of the procedure was implemented at a single centre in the Netherlands. Patients undergoing TAVR in 2013–2018 were included for retrospective analysis. Mortality was assessed in the pre-quality improvement strategy cohort (January 2013 to October 2015; cohort A) and in the post-quality improvement strategy cohort (November 2015 to December 2018; cohort B). Logistic regression analysis was used to estimate the influence of patient and procedural characteristics on the results of the quality improvement strategy in terms of procedural, 30-day, and 1‑year all-cause mortality.ResultsIn total, 806 patients were analysed with 274 patients in cohort A and 532 patients in cohort B. After introduction of the quality improvement strategy, procedural (4.4% to 1.3%, p < 0.01), 30-day (8.4% to 2.7%, p < 0.01) and 1‑year (16.4% to 8.5%, p < 0.01) all-cause mortality significantly decreased. Multivariate regression analysis showed that the quality improvement strategy also significantly reduced 30-day (odds ratio [OR] 0.19, 95% confidence interval [CI] 0.09–0.42) and 1‑year (OR 0.38, 95% CI 0.24–0.61) all-cause mortality if corrected for patient characteristics.ConclusionStructural meetings on evaluation of outcomes highlight potential areas for improvement and subsequent outcome-based quality improvement initiatives can result in lower procedural, 30-day, and 1‑year all-cause mortality.Electronic supplementary materialThe online version of this article (10.1007/s12471-020-01526-7) contains supplementary material, which is available to authorized users.     

Performance of a simplified HEART score and HEART-GP score for evaluating chest pain in urgent primary care

BackgroundChest pain is a common symptom in urgent primary care. The distinction between urgent and non-urgent causes can be challenging. A modified version of the HEART score, in which troponin is omitted (‘simplified HEART’) or replaced by the so-called ‘sense of alarm’ (HEART-GP), may aid in risk stratification.MethodThis study involved a retrospective, observational cohort of consecutive patients evaluated for chest pain at a large-scale, out-of-hours, regional primary care facility in the Netherlands, with 6‑week follow-up for major adverse cardiac events (MACEs). The outcome of interest is diagnostic accuracy, including positive predictive value (PPV) and negative predictive value (NPV).ResultsWe included 664 patients; MACEs occurred in 4.8% (n = 32). For  simplified HEART and HEART-GP, we found C‑statistics of 0.86 (95% confidence interval (CI) 0.80–0.91) and 0.90 (95% CI 0.85–0.95), respectively. Optimal diagnostic accuracy was found for a simplified HEART score ≥2 (PPV 9%, NPV 99.7%), HEART-GP score ≥3 (PPV 11%, NPV 99.7%) and HEART-GP score ≥4 (PPV 16%, NPV 99.4%). Physicians referred 157 patients (23.6%) and missed 6 MACEs. A simplified HEART score ≥2 would have picked up 5 cases, at the expense of 332 referrals (50.0%, p < 0.001). A HEART-GP score of ≥3 and ≥4 would have detected 5 and 3 MACEs and led to 293 (44.1%, p < 0.001) and 186 (28.0%, p = 0.18) referrals, respectively.ConclusionHEART-score modifications including the physicians’ ‘sense of alarm’ may be used as a risk stratification tool for chest pain in primary care in the absence of routine access to troponin assays. Further validation is warranted.Supplementary InformationThe online version of this article (10.1007/s12471-020-01529-4) contains supplementary material, which is available to authorized users.