Accepted abstracts: Poster presentations


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Title: Pulmonary embolism - What if anxiety is not just psychological?
Authors: João Ribeiro.
Keywords: pulmonary embolism; anxiety.

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Abstract: Introduction: Anxiety is many times associated to psychological ilness, especially in young patients. It can be a diagnostic, but also a symptom of an underlying cause, like pulmonary embolism (PE). Although classic presentation of PE is the abrupt onset of pleuritic chest pain, shortness of breath and hypoxia, some patients can have athypical symptoms such as hemoptysis, wheezing and ansiety itself. In this case, is presented a report of a 24 year old man recently diagnosed with schizophrenia that came to his Family Doctor (FD) with chest pain, eructation and ansiety. A common situation in young patients, but...what if ansiety means something more than a psychological symptom?

Case report: J. 24 years old. Medical History: Schizophrenia diagnosed last week, discharged three days ago. Medication: Risperidone 4mg/day. Presented to FD with anxiety and chest pain since two days ago. Pain is worst during inspiration. Had been in otorhinolaryngologist yesterday because of his throat and asked her about this pain, who said he “should come to FD, it ́s probably anxiety because this recent diagnostic, but a clinical exame should be done”. No more symptoms refered. Clinical Findings: - Stressed, worried about this pain - To 36.1, BP 121/64 mmHg, HR 121 bpm, O2 saturation 97% - Pulmonary auscultation: Can ́t deep breath because of the pain. - Cardiac auscultation: Ritmic, taquicardia. - No other findings. It was decided to refer to Emergency Room. Two weeks later, he brought a letter from the hospital: He was hospitalized with a PE and right lung inferior lobe infarction.

Discussion: PE isn't a disease itself, but a complication of underlying deep venous thrombosis (DVT), when microthrombi are formed and lysed within the venous circulatory system. When it’s not diagnosed in time, it can be fatal Association between antipsychotic and increased risk for DVT/PE has been reported since the introduction of first-generation antipsychotic drugs.Usually occurs during the first three months of antipsychotic use and is more common with atypical and low-potency typical drugs than with high-potency conventional antipsychotics

Conclusion: FD are the first line care for many patients who search for our help. Anxiety, many times undervalued by health professionals, can be hiding an underlying cause that needs emergency cares. It’s importante to value anxiety as it is and as the patient describes it. As FD, we must see our patient as a whole, seeking the underlying cause to psychological symptoms.


Title: What should a General Physician know about baby led weaning?
Authors: Carlota Veiga de Macedo, João Toscano Alves.
Keywords: infant health; food introduction; breastfeeding; baby led weaning.

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Abstract: Baby led weaning (BLW) is the name given to a new/ancient method of complementary food introduction. With this method the baby has the control of what and how much he eats while becoming in love with the textures, colours and flavours of the food itself. This way the child to be will have a better notion of satiety and a good relationship with food. The idea is presenting to the baby from the age of six months, approximately, the same food the family is having during any meal. This way the meal has a meaning of pleasure, not only from the food but also from the social environment. The food has to be healthy, and other rules have to be assured to prevent choking, low calorie intake and lack of some nutrients, like iron.In this presentation, we focus on what the physician should know about BLW to support and advise the parents that want to initiate this kind of method. Having this knowledge a physician has the power to help in altering not only the child's future, preventing diseases that start with unhealthy food habits, but also improve all the family's health.


Title: Child abuse prevention month on USF Carcavelos.
Authors: Catarina Assis Catroga, Nuno Basílio, Alexandra Fradeira, Ana Brites.
Keywords: child abuse; preventive medicine.

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Abstract: Child Abuse Prevention Month was celebrated last April and USF Carcavelos associated with this cause by inviting a group of children between five and seven years old from a nearby preschool to get to know our health center and share activities related to this campaign. The professionals from USF Carcavelos gave the children a guided tour through the facilities followed by a visualization of a few films concerning the subject of child abuse.The initiative ended with an original song created by the professionals and played with the group pf children followed by a blue balloon release.

This was a very enriching experience and we would like to share this initiative as an example to motivate primary health care centers to find new ways to send out important messages and connect with their community.

The professionals from USF Carcavelos gave the children a guided tour through the facilities followed by a visualization of a few films concerning the subject of child abuse.

The initiative ended with an original song created by the professionals and played with the group pf children followed by a blue balloon release.

This was a very enriching experience and we would like to share this initiative as an example to motivate primary health care centers to find new ways to send out important messages and connect with their community.


Title: Gastric carcinoid tumor: an uncommon challenge.
Authors: Isabel Padrão Tadeu, Mário Tadeu.
Keywords: gastric carcinoid; pernicious anemia.

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Abstract: Pernicious anemia (PA) commonly results from cobalamin deficit. The classic triad of presentation is weakness, sore tongue and paresthesias. The PA is related with a higher incidence of gastric cancer.

MLDP, female, 81 years old, previously autonomous. Personal history: alcohol consumption (5U/day), hemorrhoids. No medication. No allergies. Family history unknown. On 17th February 2017, MLDP complained of progressive weakness and shortness of breath started in January. Adding symptoms of heart palpitations, weight loss (7kg) with anorexia and lower limbs and hands paresthesias. She denied dysphagia, dyspepsia, heartburn, altered bowel habits or fever. Physical Exam: alert and oriented. Pale skin, conjunctiva normal. HF 115 bpm, BP 127/62 mmHg, BF 18 cpm, O2sat 99%, temperature 37.6oC. Cardiac and respiratory auscultation normal. Abdomen: normal bowel sounds, nontender, painless, no masses or organs palpated. Lower limbs hypoesthesia. No other neurologic symptom. Blood samples presented: pancytopenia (macrocytic hyperchromic anemia 7.8g/dL, leukopenia 1400 and thrombocytopenia 28000), cobalamin deficit 101pg/mL, folic acid normal, AST 64U/L, ALT 18U/L. No other alterations. MLDP was referred to the urgency department, where she received a blood transfusion. She was referred back to the Family Doctor for more investigation and cobalamin supplementation. During medical investigation, upper GI endoscopy showed “atrophy of the gastric mucosa of the body and fundus”. Histologic findings: “Antrum fragments show carcinoid tumor, well differentiated, insular growth pattern (chromogranin A, NSE and CAM 5.2 positives). No signs of necrosis. Body fragments partially involved in the tumor previously described, moderated atrophy. H. pylori negative.” Colonoscopy normal. MLDP was diagnosed with a gastric carcinoid tumor and referred to General Surgery.

In this case report, the identification of PA and further investigation allowed the diagnosis of a gastric carcinoid tumor. This uncommon disease represents 1% of the gastric cancers. We highlight the importance of the body and antrum histologies when an upper GI endoscopy is recommended. It is important to recognise that the treatment of anemia is, not only the supplementation, but also the investigation to provide a cure.


Title: Hypertension in 34 years old male.
Authors: Alba Gomez Zahino, Matteo Mannucci, Sara Guerrero Bernat, Laura Crespo Leza, Jordi Martínez Gisbert, Maria Dolores Acerete Hueso.
Keywords: hypertension; primary care; IgA glomerulonephritis; nephropathy; proteinuria.

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Abstract: A 34 years old male was referred by occupational health doctor to the finding high blood pressure rates, in a routinary control. Without any symptoms, the patient was found with systolic pressure 190 and 110 mmHg of diastolic. He did not present past history of hypertension or cardiovascular diseases. His medical history included hyperlipidemia and ulcerative colitis. Her medication included sulfasalazine.On examination, he was afebrile. The blood pressure was 180/100 mmHg, heart rate 80 beats per minute, the respiratory rate 13 breaths per minute, and the oxygen saturation 98% while he was breathing ambient air. He appeared healthy. Finding from heart, lung, abdomen examinations were normal.We realized blood and urine analysis that revealed a normal hemoglobin, white-cell count and platelets count. The serum electrolyte levels were normal, and the glucose level was 83 mg per deciliter. The creatinine level was 1.29 mg per deciliter (the creatinine level was 1,0 per deciliter in last test one year ago). Urinalysis showed proteinuria (150 mg/dl) and microalbuminuria (989 mg/l). His calculated glomerular filtrate (CDK-EPI) was 71,9 ml/min/1,73m2. The results of other laboratory tests were normal.Our differential diagnosis included primary hypertension, secondary hypertension due to feocromocitoma, kidney and thyroid diseases, hyperaldosteronism (Conn’s syndrome) and Liddle’s syndrome.Second line complementary tests were realized, including metanephrines and renal ultrasonography with doppler. Eco-doppler results with no structural and vascular alterations in urinary tract.We derivate the patient to nephrology, for an accurate diagnosis by the realization of a kidney biopsy, compatible with IgA nephropathy.IgA nephropathy is the most common cause of primary (idiopathic) glomerulonephritis in developed countries of the world. A regimen of antihypertensive treatment was initiated with losartan, and renal function was strictly controlled. Amlodipine was added 2 months later, because of poor control of high pressure. Since it took some month (5) to reach the diagnosis of IgA Glomerulonephritis we kept this treatment and nephrologist started with inmunosupresor treatment (corticoids and mycophenolate mofetil).From diagnosis, the patient have had a positive development with control and maintenance of the optimum blood pressure without proteinuria. He continue with periodical tests in primary attention and nephrology.


Title: Amiodarone-induced hyperthyroidism.
Authors: Raquel Sanches, Sara Carmona, Sofia Figueira.
Keywords: amiodarone; hyperthyroidism.

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Abstract: Background: Amiodarone is an effective class III anti-arrhythmic drug, commonly used to treat ventricular and supraventricular taquiarrhythmias. However, it's usually associated with several adverse effects, related with cumulative doses, even after its withdrawal. Thyroid dysfunction is a common complication of amiodarone therapy, and depends on previous thyroid status and dietary iodine intake. Amiodarone-induced thyrotoxicosis(AIT) is more common than hypothyroidism in patients with underlying multinodular goiter or latent Graves disease and in iodine-deficient regions, and is more frequent in males. There are two types of AIT, and differentiation between them is critical, due to their distinct pathogenesis, treatment and outcomes. Sometimes, mixed forms of AIT exist, making both diagnosis and treatment challenging.

Case presentation: An 82-year-old portuguese female medicated with amiodarone for atrial fibrillation since 2013, presented with complaints of heart palpitations, anxiety, weight loss, insomnia, dizziness and recent lipothymic episodes. At physical examination, the only abnormal findings were bradycardia and irregular heartbeat. She had no previous radiotherapy exposure, personal or family history of thyroid disease. Laboratorial evaluation showed low TSH(<0,004 uUI/mL) and high fT4(2,14 pmol/L). Owing to these results, amiodarone was discontinued and the patient was referred with urgency to endocrinology service. Further investigation showed normal anti-thyroid antibodies and a micronodular pattern. In this context, the hypothesis of AIT was considered, and therapy with thiamazole and prednisolone was started, with clinical and analytical improvement in less than 5 months.

Conclusion: We describe a challenging case of AIT in a female, with no previous thyroid dysfunction, living in Portugal, where iodine intake is believed to be low. We have no information about thyroid vascularity, IL-6 or radioiodine uptake, which would help to distinguish the two types of AIT. When the distinction is difficult, partly because some patients may have a mixture of both mechanisms, it's reasonable to start a combined therapy. In this patient, the rapid response to therapy, along with the absence of previous thyroid dysfunction, may suggest prevailing type 2. This case shows the relevance of controlling thyroid function in patients treated with amiodarone and also the need to be aware about the side effects of medicines prescribed to our patients.


Title: Overdoing in community medicine: a case report coping with a renal incidentaloma.
Authors: Tom Axelrod.
Keywords: overdoing; overdiagnosis; overtreatment; renal incidentaloma.

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Abstract: Case presentation: A 71 years-old lady with a 4 years history of NIDDM discovered on routine lab tests and a well-balanced hypothyroidism. No other findings on history, anamnesis or physical examination. Laboratory exam was normal except for HbA1c and glucose values. After 2 years of balanced diabetes using oral medications only, her HbA1c starts to rise. She was put on insulin, but remained unbalanced. Upon her request, she was referred to an endocrinologist who suggested performing an abdominal CT to rule out pancreatic involvement that might explain the new-onset treatment-resistant diabetes. Her abdominal CT showed no pancreatic or other abdominal organs pathologies, apart from a 1.5mm non homogenous, irregular solid process on the cortex of the right kidney.

Discussion: The workup of renal incidentalomas is challenging, especially for the non-cystic middle-sized tumors. The differential diagnosis of such tumors ranges from benign (e.g. angiomyolipoma) to malignant (renal cell carcinoma) tumors. The guidelines are not straight forward due to lack of high quality evidence. The treatment approaches ranges from a partial nephrectomy to follow-up policy. It has been estimated that over half of those aged above 50 have at least one process on one of their kidneys, and that 30% of kidney tumors smaller than 3 cm are benign.Conclusion: While data from Australia and US of the past 45 years show steady increased incidence of renal tumors, there is no changes in mortality from those tumors - suggesting a pendulum tilt toward overdiagnosis, which in turn might lead to overtreatment.


Title: Relationship between general practitioners’ job characteristics and their attitudes towards self-assessment glycaemic control (S-AGliC) practices.
Authors: Jurate Peceliuniene, Irena Zukauskaite, Antanas Norkus.
Keywords: self-assessment of glycaemic control; job characteristics; job satisfaction; general practitioner; supervisor; diabetic primary care patients.

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Abstract: Introduction: The systematic adherence to S-AGliC is a key element to obtain a positive therapeutic effect in diabetic patients.

Methods: Pilot study was performed to evaluate the impact of general practitioners (GPs) job characteristics and their attitudes towards S-AGliC practices and adherence among diabetic primary care (PC) patients. 24 consecutive GPs took part in the study. Five aspects of job satisfaction (current career, possibilities for qualification improvement, work in a team, cooperation and communication with specialists, and access to work equipment) and job satisfaction in general were measured on 5 item Likert type scales. Perceived supervisor (S) support was measured by short version of Greenhaus, Parasuraman ir Wromley (1990) scale. GPs had to indicate their fatigue at work as well as stress on 10 point Likert type scales.

Results: The importance of patients’ S-AGliC practices and adherence was related with different aspects of S support for GPs: the correlation with GPs' recognition was r=0,438, p=0,035; the correlation with the feedback provided to GPs by S was r=0,462, p=0,027; and the correlation with GPs' development conditions was r=0,476, p=0,022. GPs' satisfaction with possibilities for qualification improvement was related with three aspects: correlation with the impact of S-AGliC on diabetes control/correction/HbA1C% was r=0,416, p=0,043; correlation with the time, needed for GPs to consume for patients’ S AGliC was r=0,413, p=0,045; and correlation with perceived patients' harm and benefit ratio of S-AGliC was r=0,475, p=0,019. The satisfaction with access to work equipment correlated significantly with the impact of S-AGliC on diabetes control/correction/HbA1C% as well with the time, needed for GPs to consume for patients’ S-AGliC. Patients’ S-AGliC and cooperation with his/her GP were both significantly related with doctors’ fatigue and stress at work.

Conclusions: The importance of patients’ S-AGliC is related with supervisor’s support for GPs. GPs’ fatique and stress at work both are related with better GPs' and patients’ cooperation regarding S-AgliC.


Title: What do young doctors know of Palliative Care; How do they believe the concept should work?
Authors: G Chamath Fernando, Shamini Prathapan.
Keywords: palliative care education; medical education; undergraduate curriculum

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Abstract: Introduction: Education in the relatively modern discipline of palliative care is still evolving in developed parts of the world while it remains at an infantile stage in developing countries like Sri Lanka which has not also been formally assessed as of today.

Aims: To evaluate the level of palliative care knowledge among young medical graduates and to identify their opinions on the discipline.

Methods: A descriptive cross-sectional study was carried out among pre-internship medical graduates of Sri Lanka through a social media based on-line survey. The sample size recruited was 351. The pre-tested questionnaire contained questions with regards to general principles, service organization, management, ethics related to palliative care and their opinions.

Analysis: The results were analysed in the form of average and percentage scores overall and in each domain.

Results: The average score among the respondents was 37.25% with a standard deviation(SD) of 11.975. Specific knowledge on “general principles” was adequate (score&gt;=50%) with an average of 62.61%,SD=24.5 while “ethics” was observed to be the area with poorest knowledge (average score=19.55%,SD=22). Average scores for “service organization” and “managerial aspects” were 34.54%,SD=17.6 and 32.26%,SD=22.3 respectively. The majority (&gt;90%) believed that de-novo establishment of hospice, hospital and community-based palliative services would sustainably improve holistic patient care.

Inference: The fresh medical graduates are poorly knowledgeable about the basic concepts of palliative care and end-of- life issues. A sound palliative academic programme must be incorporated into the undergraduate medical curricula. It is worthwhile to assess the adequacy of learning of Palliative Care through postgraduate curricula.


Title: Biophysical attributes, bone densitometry scanning revealed dimensions and interrelations between them; an urban Sri Lankan study.
Authors: Kavijaya Wijayasinghe, G Chamath Fernando, Chandima Jeewandara, Shyamalee Samaranayaka.
Keywords: osteoporosis; urban population; dual energy X-ray absorptiometry.

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Abstract: Introduction: Osteoporosis and osteopenia can be detected sensitively by Dual Energy X-ray Absorptiometry (DEXA) which then can be remedied by pharmacotherapy and lifestyle modification strategies, thus preventing foreseeable jeopardy to quality of life.

Objectives: To describe the biophysical attributes, bone densitometry scanning revealed dimensions of the patients undergoing DEXA scanning at an urban primary care centre and describe interrelations between them.
Methods: A descriptive study where all the retrospective data of patients who underwent DEXA scanning were analysed in terms of percentages of and interrelations (with Pearson’s Chi-square-#2) between biophysical data and densitometry parameters (e.g. T,Z-scores, fat mass etc.).
Results: A total of 604 (females=539, age range=30.61 - 88) were included in the analysis out of all individuals scanned. Based on the left hip T-scores, 6.8% were osteoporotic and 27.3% were osteopenic. Spine and Whole Body (WB) T-score results revealed that 34.8% and 35.1% were osteoporotic while 39.2% and 34.9% were osteopenic respectively. WB, Hip and Spine T-scores significantly correlated directly with Body Mass Index (BMI), (#2=53.403, p<0.001); (#2=108.253, p<0.001); (#2=64.002, p<0.001) respectively. WB, Hip and Spine T-scores also had significant inverse correlations with age (#2=177.312, p<0.001); (#2=104.073, p<0.001); (#2=135.173, p<0.001), years elapsed since menopause in females (#2=147.863,p<0.001); (#2=76.864, p<0.001); (#2=150.689, p<0.001) and females being included in ‘metabolic syndrome’ defining waist circumference category (#2=22.576,p<0.001); (#2=58.717, p<0.001); (#2=19.667, p<0.001) correspondingly.

Conclusion: More than a third of the screened urban population were osteoporotic while another third was identified to be osteopenic based on spine and WB T-scores. Overall T-scores were significantly influenced favorably by BMI and adversely by age, time since menopause and female waist circumference.





Title: What if it’s ALS?

Authors: Maria João Sousa, Maria José Almeida.

Keywords: fasciculations; anxiety; Benign Fasciculation Syndrome.

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Abstract: Introduction: Fasciculations are a common symptom, occurring in about 70% of healthy individuals. They are rarely associated with serious disorders, but they appear to be a cause of anxiety, particularly among health professionals, since they can be an early symptom of serious diseases, such as Amyotrophic Lateral Sclerosis (ALS).

Case Report: A 24 year-old female, physician, with a functional nuclear family and history of migraine, consulted her family physician (FP) due to fasciculations “from head to toes” (more commonly in upper eyelids, upper and lower limbs, but also in the abdomen, thorax, face and tongue), that only occurred at rest, ceased immediately with movement and were visible under the skin. She started to experience this, but only in her legs, 1 year before, during her last year in medical school, while studying for an important exam. When the patient started working as a doctor, 2 months after the exam, the fasciculations got much worse in frequency, amplitude and extent and by this time were accompanied by sporadic episodes of paresthesias, especially in her feet, hands and face. There was no muscle weakness. She was extremely anxious and worried about the possibility of ALS. The neurological examination (NE) was normal. Magnesium was prescribed and blood tests requested, including thyroid function, sedimentation velocity, C-reactive protein and antinuclear antibodies, with no alterations in any of these. Because the patient was still worried and wanted to rule out the possibility of a serious condition, a Neurology appointment at the hospital was requested. An electromyography and a global NE were performed; they were both normal. Therefore, the neurologist assumed the fasciculations were benign and stress-related. Diazepam in a SOS regimen was prescribed. Six months later, the patient had an appointment with her FP – she maintained the fasciculations and acknowledged they worsened when she was more anxious, but overall the symptoms had clearly improved.

Discussion: The majority of fasciculations are benign, but causes like motor neuron diseases must be ruled out before the diagnosis of Benign Fasciculation Syndrome (BFS) can be made. Despite its benign course, in some cases BFS can be a source of physical and psychological morbidity and interfere with quality of life. The FP is frequently the first professional to whom these patients resort. Therefore, they play an essential role on the initial approach and on providing an adequate follow-up.

Title: When bone fracture led to Turner Syndrome diagnosis.
Authors: Ana Sequeira, Vera Araújo, Ana Maria Pires.
Keywords: Turner syndrome; primary care management.

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Abstract: Background: First consultations with a General Practitioner (GP) seldom start at 55 years. They usually begin with prenatal care, then neonatal care, first and second years of life, childhood, teenage years and adult life, providing longitudinal continuity of care until death (and grief period for relatives).

Therefore, it is important to fully evaluate all patients the first time they enter in our consultation room, and take an adequate family history. However, such process is gradual, and may take several consultations.
Description MDCV, female patient, 56 year-old, single, retired (farmer), belonging to a large family, had first contact with her GP on 16.06.2016. It was a non-presential consultation for registration of an emergency room (ER) letter referring surgical correction of diafisary fracture of both tibial and peroneal left bones (following an accidental fall), and pacemaker introduction due to a symptomatic complete atrial-ventricular blockade (unknown previously to this ER episode). The GP then scheduled a presential consultation in order to access the patient. The GP took the clinical history, including family history and evaluation. During the interview the patient revealed absence of menarche. MDCV had an aged appearance and physical examination showed excess weight, short stature, high blood pressure, and short neck, as well as abnormal hairiness in the chest, poorly developed breasts and her vaginal inner labia were not visible. Considering the findings, further investigation (blood analysis and imagiology) took place in subsequent consultations and was also requested an endocrinology consultation. Hormonal study and karyotype were performed. The results showed hypergonadotrophic hypogonadism, and turner syndrome was genetically confirmed.

Currently, besides GP consultations, this patient also attends hospital consultations: endocrinology, cardiology, urology and otorhinolaryngology, due to syndrome complications; but with medication and close follow-up, she continues to live a normal functional life.
Discussion Turner syndrome is a chromosomal condition that affects development in females (approximately 1 in 2000) and its diagnosis is usually made at the age of five, due to its clear phenotype.

This case report highlights both the importance of adequate personal and family history taking and clinical awareness of genetic conditions by the GP and also his pivotal role in patient care management and coordination with secondary health care.


Title: Patient, community and health professionals: charting the course together for better health.
Authors: Ana Luísa Esteves, Diogo Silva, Elvira Teles Sampaio, Liliana Silva.
Keywords: primary care; teamwork.

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Abstract: Introduction: The central attributes of primary care are accessibility, patient-oriented comprehensiveness and coordination. These are consistent with an integrated people-centred approach, placing people at the heart of health system. To achieve this goal, Primary Care Units need to be high-quality, effective and efficient, trying to bring together the patient, the community and health team workers. In order to empower and engage people, the health care providers must be skilled and motivated. The Serpa Pinto Primary Care Unit identifies itself with the participatory management model, working to increase accessibility and promoting professional cohesion and satisfaction, through a panel of strategies.

Description: The Serpa Pinto Primary Care Unit project is based on three main pillars: patient, community and health team workers. To achieve patient’s wellbeing, the Serpa Pinto Primary Care Unit has the daily support of LAUS (Serpa Pinto’s Friends League, an institution of social solidarity), trying to improve patient social conditions, their health status and quality of life. Other strategies, such as team building activities, allow the health workers to increase teamwork skills and motivation. Some examples are: 5th Wednesday (a playful moment taking place when the month has five Wednesdays), Serpa Pinto’s Birthday, Christmas Party and weekly meetings, with specialists and residents, with 5 minutes of culture. Other projects, such as Actividade (health education project in a nursing home), celebration of Family Doctor's day (19th May) and the residents’ newsletter (For our health!) are great opportunities to empower and interact with the community. The Serpa Pinto Primary Care Unit team believes that all of the strategies listed above contribute to strengthening the health system, improving teamskills and healthcare delivery to people, their families and community.

Conclusion: As teamwork should be considered the basis of the health work process, relational skills are increasingly important. A regular contact and a coordinated action between the multiprofessional teams, as well as a proper environment to their functioning, are essential for a better healthcare service.

Concluding, the Serpa Pinto Primary Care Unit team is developing a number of strategies in order to achieve team cohesion, minimize the distance between health care providers, patients and community and chart the course to navigate the future. Because we are “stronger together”


Title: “Thinking outside the box" - about a red blood cell count prescription.
Authors: Ana S. Fernandes, Diana Coelho, Maria Antónia Alvito.
Keywords: red blood cell count; guidelines; gastrointestinal stromal tumor.

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Abstract: As family doctors we follow a clinical thinking that is focused on the patient, having local guidelines has guidance. This case shows how, sometimes, our clinical practice must be individualized according to the patient and how the prescription of complementary exams can change a person’s life.

This is a case of a male of 40 years old, autonomous in his activities of daily living, inserted in a stable nuclear family, with a daughter in school age, and a close relationship with his mother and brother. He presented to our routine hypertension appointment asymptomatic, with a normal physical examination and with laboratory tests showing a microcytic hypochromic anemia, that later was confirmed as a ferropenic anemia. In the etiological investigation performed later, in order to discover gastrointestinal blood losses, stands out: a colonoscopy without any relevant alterations and a upper gastrointestinal endoscopy with a subepithelial lesion of the second portion of the duodenum. To clarify the lesion he performed an abdominal and pelvic tomography with contrast which demonstrated the presence of an oval image with a soft tissue density and an upper gastrointestinal endoscopic ultrasound where it stands out, in the second portion of the duodenum, a subepithelial lesion suggestive of a gastrointestinal stromal tumor (GIST) of the duodenum, later confirmed by histology. Due to this diagnose the patient was refered to the specialty of general surgery, and submitted to duodenum pancreatectomy with cholecystectomy.

According to the local guidelines, the prescription of a red blood cell count obeys to very specific rules. However, as family doctors we have to adequate our clinical practice to individual particularities of the patient in front of us. This case report makes us reflect about the benefit of prescribing complementary exams, has a red blood cell count, in certain cases, rather than being strictly faithful to the local guidelines. In this case report, the anemia diagnostic allowed a fast etiological investigation, consequently allowing the diagnosis of a GIST in an initial phase. This early diagnosis was fundamental for a surgical treatment that has a high curative potential. For this patient, in particular, the prescription of a red blood cell count completely changed his and his family's life.


Title: When we believe in a miraculous oil.
Authors: Ana S. Fernandes, Diana Coelho, Maria Antónia Alvito, Alexandra Fernandes.
Keywords: cannabis oil; alternative treatment, conventional treatment; metastatic neuroendocrine tumor.

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Abstract: The patient-centred clinical method considers his customs and beliefs. In this context there are situations in which it is necessary to achieve a balance between the conventional medicine and alternative treatments proposed by the patient.

This is a case of a male of 64 years old, from Mozambique, twelfth grade of scholarship, autonomous in his activities of daily living, inserted in a nuclear family. He presented to our appointment with stomach fullness and severe weight loss. We observed a discrete hepatomegaly, without any chronic liver disease stigmata. It was requested an abdominal ultrasound and laboratory tests with liver parameters which revealed a severe hepatomegaly, hepatic, heterogeneity of liver parenchymal with multiple nodular formations and an increased cholestasis pattern. After reading the results of the exams the patient decided to start a treatment with cannabis oil, refusing conventional medicine therapeutics, until the end of it, which was accepted by the family doctor. It was prescribed an abdominal tomography that showed a severe hepatomegaly with multiple metastasis. The patient was refered to the specialty of gastroenterology and was diagnosed with a neuroendocrine tumor of the tail of pancreas with liver metastasis. By the end of the alternative treatments he accepted to start chemotherapy.

With this clinical case we pretend to alert family doctors that our clinical practice must be individualized according to the particularities of the patient, namely his beliefs, that in this case were fundamental to the patient cooperation in his treatment.


Title: Urinary tract infection complicated by a ureteral stone.
Authors: Emanuela Gomes, Pedro Namora, Salete Gomez, Helena Ribeiro, Fernando Carvalho.
Keywords: urinary tract infection (UTI); UTI complicated; ureteral stones.

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Abstract: Background: This case intends to address the relevance of the diagnostic and therapeutic individualization that should be applied to the complicated urinary tract infection, considering the patient's clinic their background and level of risk. The importance of patient follow-up is highlighted in order to monitor the clinical evolution, as well as early detection of associated complications and the prevention of additional acute episodes.

Case presentation: A 37 y/o women went to the emergency department (ED) for sudden severe low back pain, July/2015. The urine test strip showed leukocyturia and nitrituria. Abdominal radiography revealed a renal pelvis stone in the left kidney. The clinical condition was interpreted as cystitis and medicated with fosfomycin and butylscopolamine. The family doctor (FD) prescribed analgesia and changed the antibiotic for amoxicillin/clavulanic acid. Due to persistence of symptoms and renal echography with evidence of hydronephrosis associated with proximal ureteral stone, the FD immediately referred the patient to the ED. She was hospitalized with a obstructive acute pyelonephritis with need of a percutaneous nephrostomy. Following the failure of extra corporeal shockwave lithotripsy in Oct/2015, retrograde intrarenal surgery was proposed to May/2017. In the meantime, she went to the ED with new episodes of low back pain with subfebrile state, renal murphy, leukocyturia and nitrituria. She was hospitalized for surgery, which was prolonged and complicated by sepsis requiring broad spectrum antibiotic therapy.

Discussion: It is important to highlight the emotional and economic impact of the clinical situation presented. On one hand, the fear of new acute episodes and the risk of complications were present; on the other hand, the incapacity to perform their professional activity was also recurrent, which was extended to activities in the personal and family sphere. The maintenance of surveillance by the FD was essential in the emotional support. The support in the clinical aspect through the substitution of antibiotics and signalling of severe clinical picture it was also crucial. However, this clinical case also warns to the relevance of optimizing communication between primary and secondary healthcare. Only through a solid partnership between the two types of healthcare levels it will be possible to detect these conditions early, reduce the risk of complications and improve the health status and quality of life of the patients.


Title: Discovering polygamy through infertility - a case report.
Authors: Tatiana Macedo Pinto, Margarida Pereira, Mariana Moura Relvas, Maria do Carmo Gonçalves.
Keywords: polygamy; infertility; family medicine.

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Abstract: Introduction: Foreign patients present many challenges in our daily clinical practice. The religious, cultural and social contexts often differ from our reality and the language barrier is one of the biggest struggles. The project of parenthood is held by many people and the importance that each individual attributes to parenthood may be influenced by many factors, including cultural ones. Infertility is defined by the World Health Organization as a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after twelve months or more of unprotected sexual intercourse.

Goals: With this case-report of a couple with infertility the authors aim to highlight difficulties in the clinical practice with foreign patients, particularly with patients from different cultural contexts and when there is a language barrier; to evidence the role of the family doctor in the foundation of a relationship of clinical proximity; and to contextualize polygamy in the portuguese law.

Case description: This is a couple from an african country: T., female , 37 years old (now 45) and M., male, 42 years old (now 50). Muslim religion. They began their follow up at our health unit in 2009. Since the first consultations there were communication difficulties: T. did not speak portuguese (only an african dialect) and M. spoke some portuguese and translated. In the first appointment with the couple, they intended to continue the infertility study they initiated in private practice. They were married for 20 years, had no children of their own and denied having children with other partners. They had no medical history other than infertility (reported 10 years before) and obesity. With the years, the language barrier diminished. Eight years and many myths, treatments, negative pregnancy tests, appointments and a perimenopausal amenorrhea later, T. continues to pursue the idea of getting pregnant and having a child. And at this stage, digging deeper, we discover that M. practices polygamy and has married two other women, with one of whom he has a child.

Discussion: The continuity of care, characteristic of family doctors, allows us to get to know our patients. In this case, the establishment of a relationship of clinical proximity was fundamental for understanding the importance of preserving fertility for this patient. Discovering the practice of polygamy helped us better understand T.’s frailty and made us wonder about the legal framework of polygamy in our country.


Title: Thoracic Outlet Syndrome in primary care, a clinical case report.
Authors: Matteo Mannucci, Gabriel Trucco, Alba Gomez Zahino.
Keywords: primary care; thoracic outlet syndrome; cervical rib syndrome.

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Abstract: Thoracic outlet syndrome (TOS) refers to a group of signs and symptoms due to the

compression of the neurovascular bundle by various structures in the area above the first rib and behind the clavicle in the region of the thoracic outlet. This syndrome is known with different names, like cervical rib syndrome, scalenus anticus syndrome, costoclavicular syndrome and hyperabduction syndrome.

A 57 yo male patient presented to his family doctor consultation with a complaint of a pain and swelling in the left elbow since a couple of weeks. Pain depends of movements and position, it increases with abduction of the left arm. He refers no previous traumatism. He also shows a long time edema in both hands associated with a past history of arthrosis due to his work as cook. He is active smoker (15-20 cigarettes per day). At physical examination no movement limitation or neurological abnormalities were shown. Mild increase of superficial venous circulation in the left hemithorax, not seen in the left arm. Soft swelling of left arm with 31 centimeters diameter (while on right arm, diameter was 27 cm). Mild swelling of both hands, with no signs of inflammation. No lump in armpit was found. Selective pain in epicondyle. Radial pulse presents in any position of the arms. JVP was not raised, cardiac auscultation shows regular heart rate without murmurs, while pulmonary was clear to auscultation bilaterally, without wheezes or crackles.

With the diagnostic of epicondylitis and a suspect of a thoracic outlet syndrome we selected a Chest X-Ray as complementary test that didn’t shown any abnormalities and prescribed a nonsteroidal anti-inflammatory drugs (NSAIDs) treatment. We sent him to an emergency angiology specialist consultation to realize Doppler ultrasound that didn’t show any thrombus in cephalic, basilic, humeral, axillary, subclavian and jugular veins. No flow signal with hyperabduction of the left arm.With the suspicion of venous thoracic outlet syndrome he was discharged from emergency, added in waiting list for venography and referred to angiology specialist regular appointment.Images from the venography that showed stenosis in both subclavian veins with 90 degrees abduction of arm.After his appointment with the specialist they commented the clinical case in a Committee and decided for surgical first rib removal.


Title: Enhancing management of obesity in Al Bateen health care center in Abu Dhabi, United Arab Emirate, in 2016.
Authors: Bushra Ghaliani, Fatma Nasser, Asma Mazroie, Mouza Neimie, Eiman Alshehi.
Keywords: obesity.

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Abstract: Introduction & Background: Obesity is a global epidemic that considered one of the biggest health problems currently. Obesity rates have been increasing according to the latest records of health authority’s preventive program in Abu Dhabi. In 2013, they found that 2/3 of Emirati adults were overweight or obese. We aimed to evaluate and improve obesity management in Al Bateen clinic according to recommended guidelines.

Methodology: Retrospective study carried out in Al Bateen clinic during 2014 followed by re-audit in 2016. We implemented interventions like conducting frequent lectures and recommendations for dietician and obesity clinic. We targeted patients who have BMI of 25 and aboveand agedbetween 18-60 years. 2618 patients met our inclusion criteria.Systematic randomizationwasusedwith sample sizeof366 based on sample size calculator 95% CI. Percentages, means and frequenciesofoverweight and obese patients were calculated for two visits through excel sheet. Documentation oflifestyle modifications education and diabetes screening were checked..

Results: Average age of the patientswas 42 years. 36% were males while 64% were females. Percentage of obese class III was 21.8% in 2014 and became 11.3% in 2016. On the other hand, obesityclass II and obesityclass Iwere 27% and 38.8% which increased to 32.1% and 52.1% respectively.

Overweight was 12.4% and became 4.5%. Furthermore, normal BMI in 2014 increased by 0.4% in follow up visit while it increased by 0.3% in 2016. Screening for diabetes in overweight and obese patients improved from 76% in 2014 to 89% in 2016 while documentation of lifestyle modifications education was dramatically increased from 87% to 96%.

Discussion: There was a notable increase in the assessment of CVD risk by checking blood sugar and assessment of lifestyle modification (diet and/or exercise) due to reminders, lectures and availability of dietician. However, a decrease in normal BMI was observed due to limited insurance coverage for dietitian services.

Conclusion: Encouraging physicians to screen obese patients for diabetes and educate them about lifestyle modification have significantly improved quality of care.

Recommendation: We recommend doing educational campaigns for the public about obesity and distribute educational leaflets for obese patients. Also to continue periodic reminders of obesity management guidelines Re-auditing is essential to mark the progress which will be done in one year.


Title: Vaccination for teenage pertussis - kills less and saves more?
Authors: Catarina Ferreira, João Vieira Fonseca, Paula Neves, Nuno Amaral, Pedro Apolinário.
Keywords: vaccination; pertussis; adolescence.

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Abstract: Introduction: Whooping Cough is a respiratory infection caused by highly contagious Bordetella pertussis. Infants and young children are the most vulnerable group. The current Portuguese National Vaccination Program contemplates vaccination for pertussis at 2, 4, 6, 8 months and 5 years of age, as well as all the pregnant women, ideally at 32 weeks. However, this (Dtpa) vaccine ́s application in Portugal has been used instead of tetanus and diphtheria isolated at 10 years old or as an reinforcement in adolescenthood. This evidence-based review aims to assess the impact of the pertussis vaccination (Dtpa) in adolescents at two levels: mortality and cost-effectiveness.

Methods: in May 2017 articles were searched in the electronic databases Pubmed, Cochrane Library, DARE, Bandolier, Guideline Finder, National Guideline Clearinghouse, National Institute of Health and Care Excellence and Index of Portuguese Medical Journals. There were included the following: systematic reviews, meta-analysis, randomized clinical trials, multicenter and observational studies. We aimed to compare the adolescent's population from 10 to 18 years old who were vaccinated with Dtpa with the ones who were not. The Mesh terms used were "Whooping Cough" AND "DTaP vaccine" AND ("adolescent" OR "child") AND ("mortality" OR "cost effectiveness"). The chosen languages were english, spanish and portuguese between the years of 2000 and 2016.
Results: were found 23 articles and included 5: 2 prospective cohorts, 2 cross sectional observational studies and one consensus of experts, which globally evidenced the benefit of pertussis vaccination in adolescence (Dtpa).
Conclusions: this review shows a potential gain with Dtpa vaccination between the ages of 10 and 18 with an average level of evidence of 2. Although it does not appear to reduce the mortality rate associated with whooping cough, it reduces the number of hospitalizations, provides a better immunity and indirect protection for younger children. However, not only more effective studies of pertussis incidence are needed but also cost effectiveness studies with longer follow-up.






Title: In the eye of a host: a Hippokrates exchange.
Authors: Süheyla Atalay.
Keywords: Vasco da Gama Movement; exchange; primary care training.

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Abstract: Introduction: There are different types of exchange programs under the roof of Vasco da Gama Movement . One of them is the hippokrates exchange which was launched 17 years ago. The Hippokrates Exchange is an exchange programme for medical doctors specialising in Family Medicine/General Practice and junior Family Doctors/General Practitioners (within 5 years of completing specialty training). The programme is supported by WONCA Europe and by the European Academy of Teachers in General Practice (EURACT).The aim of Hippokrates is to encourage exchange and mobility among young doctors in the course of their professional formation as General Practitioners; thus providing a broader perspective to the concepts of Family Medicine at both professional and personal levels.

Aim: The aim of the abstract is to present the opportunities of participating as a host in a hippokrates exchange
Methods: Between the dates of 15/05/2017 to 26/05/2017 hippokrates exchange for Nahla-El Eraky from UK took place in Istanbul hosted by me in Marmara University Training and Research Hospital, Family Medicine Department. Before her arrival, my tutors and I have prepared an educational two weeks program according to her learning objectives which includes family medicine residency education, home visits, primary care centers, refugee health, research in primary care ... etc. After her arrival we made minor needed changes on that program. During her stay, she also met local trainees and attended local teaching sessions. In one of them, Nahla gave us an excellent presentation about being a GP in UK. In our mutual free time with Nahla, we travelled around this beautiful city, Istanbul.

Results: Exchanges have shown to be beneficial for both visitors and hosts as they promote participants to get out of their comfort zone and to rethink how they may improve Primary Care provision for the population they work with.It became clear that there are differences between UK and Turkey health systems, on the other hand, we deal with the same problems in our daily clinic life and doctor patient relationships.. The experience and the possibility of comparing both health systems enriched our vision. A Hippokrates Exchange gives a new skill to the host; multi-managing. Cooperating with the professors, the colleagues, other workers and putting a visit to them in order is not an easy task to achieve. All worth to see the learning objectives are achieved and reading the final report.


Title: Rhinosinusitis - Are we treating it properly? Quality work.
Authors: Rita Oliveira da Silva, António João Costa e Silva.
Keywords: rhinosinusitis.

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Abstract: Justification: The Rhinosinusitis (RS), frequent in primary health care (PHC), according to the European Position paper on rhinosinusitis and nasal polyps (EPOS) 2012, results from the nose and sinus inflammation with # 2 symptoms: one of which is nasal obstruction or rhinorrhea, facial pain and/or hyposmia. It impacts the quality of life, implying the need of medical care and incapacity for work. Adequate intervention and therapy in PHC allow a reduction in morbidity and absenteeism to work.

Objective: To evaluate and improve the quality of care provided by guaranteeing the clinical diagnosis of RS and adequate therapy according to EPOS.
Methodology: Analytical, cross-sectional and retrospective study, before and after internal educational intervention. Data collected from MIM @ UF® and SClínico® computer records and processed in Microsoft Excel®2016. Population: Adults #18 years from an family health unit (FHU) with “A” of SOAP coded: R75 of the ICPC-2 during an episode of the 1st semester 2016 (1st evaluation) and from 12/2016 to 05/2017 (2nd evaluation). Variables: age, sex, clinical findings, severity and therapeutics. Evaluation and quality criteria: No and % of patients with R75 diagnosis, clinical findings and adequate therapy, checking for improvement after intervention. Results: In the 1st evaluation, 70 patients were eligible, 62,9% with symptoms compatible with the clinical diagnosis, 44,3% with severity criteria. In the prescribed therapy, 85.7% under antibiotic, 54,3% nasal corticosteroids, 40,0% NSAIDs, followed by antihistamines (AH) in 32.9% and nasal irrigation in 2.9%. In the 2nd evaluation, 80 patients were eligible, 72,5% with symptomatology compatible, 43,8% with severity criteria. Regarding therapeutics, 77,5% had antibiotic, 8.8% of which had a different dosage than the recommended one, 61.3% had a nasal corticosteroid, 31.3% NSAIDs, 13.8% nasal irrigation and 26.3% had AH prescription.

Discussion: There was a reduction in the prescription of antibiotics, good to avoid resistances. Of note is the improvement of symptomatic treatment through corticoid and nasal irrigation, which allow the significant reduction of the symptoms and morbidity associated with RS, often chronic and likely to limit quality of life. The omission of data in computer records and the comparison between selected samples at different times are some of the limitations of the study. It is important to undertake new peer intervention to improve multi-morbidity in PHC.


Title: Infectious mononucleosis: importance of Group A Streptococcus rapid antigen detection test.
Authors: Nuno Parente, Joana Castro.

Keywords: Infectious mononucleosis; Group A Streptococcus; rapid antigen detection test.

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Abstract: Context: Infectious mononucleosis (IM) is defined as a classic triad of fever, pharyngitis and cervical adenopathy. In 90% of cases there's an Epstein Barr virus (EBV) infection. In childhood the primary infection is typically asymptomatic. Complications include meningoencephalitis, acute airway obstruction, spleen rupture and an increased risk of lymphoproliferative cancer.

In Portugal, acute tonsillopharyngitis has an incidence of 111 000 cases per year and is the respiratory disease responsible for the most antibiotic prescriptions in primary healthcare. Today, when a acute bacterial tonsillopharyngitis is suspected is advised confirmation with Group A Streptococus rapid antigen detection test (GAS-RADT).

Description: African Portuguese female, 8-year-old with previous records of allergic rhinitis and asthma exacerbations. No history of adverse drug reactions (ADR). Presented to the emergency department (ED) complaining of fever and odynophagia and was started on amoxicillin 50 mg/Kg/day PO for an an bacterial tonsillopharyngitis. She was on the third day of amoxicillin course when she presented to primary care setting with aggravated odynophagia, intense malaise, neck congestion, painful cervical lymphadenopathy and bilateral tonsillar exudate. Referral to the ED was made for thorough investigation. At admission she was clinically unwell and laboratory studies showed an absolute lymphocytosis, presence of atypical lymphocytes and a Monospot-positive test. She was started on intravenous prednisolone 1 mg/Kg and discharged on an oral corticosteroid. Parents were counseled on the potential complications.

Discussion: IM diagnosis demands clinical suspicion and analytical evaluation. The availability of GAS-RADT throughout primary care centres (PCC) will allow the reduction of overtreatment in viral infections that induces antibiotic selective pressure and exposes patients to ADR. The GAS-RADT, although operator-dependent, provide the most cost-effective solution. The inclusion of GAS-RADT in PCC clinical protocols and its systematic use can decrease health-care related expenditures by 42%. It's important to highlight the family doctor role in dealing with acute problems and sometimes in early undifferentiated stages.


Title: One more minute could save a life.
Authors: Raquel Georgina Padin Perez, Elena Torices Picon, Maria dolores Vazquez Garcia, Marta Colón Más.
Keywords: appointments and schedules.

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Abstract: In this clinical case, we present a 56-year-old male in which the clinical history, complete physical examination and prevention protocols allowed the diagnosis of a life-threatening disease in an asymptomatic patient.

This is a 56-year-old man who comes to his health centre for the first time to consult on the appearance of a dermic lesion. In the absence of information about the patient, and despite being asymptomatic, a complete medical history is made with the following findings: previous history of an unknown heart intervention performed during childhood without any further reviews, arterial hypertension, obesity grade I and a systolic murmur of moderate intensity. An electrocardiogram and an echocardiogram are prescribed. One month later, he returns with the results of the electrocardiogram, which reflects an elevation of the ST segment in V2 to V4 precordials. In view of this result, an electrocardiogram is repeated in that moment where normalization of the ST segment and negative T waves are observed in I and avL. The patient continues asymptomatic, in functional class I and daily cycling more than 50 kilometres. In the presence of cardiovascular risk factors and electrocardiographic changes that suggest myocardial ischemia, the same day, the patient is referred to the hospitals emergency service. During the following month and after undergoing complementary tests, the presence of a 7,1 cm aortic aneurism is discovered, as well as aortic valvulopathy with severe insufficiency due to ring dilatation and moderate pulmonary hypertension. Given these results, the patient is scheduled for cardiovascular surgery and is currently recovered.

With this case we intend to reflect the importance of following prevention protocols properly using a good clinical interview and detailed physical examination of our patients, without focusing only on the symptom or isolated sign that motivated the visit. This allows an adequate diagnosis and early treatment of potentially serious and preventable diseases from Primary Care.


Title: Diagnosing collagenous colitis is stopping diarrhea.
Authors: Sofia Rocha Teixeira, Mariana Madureira.
Keywords: collagenous; colitis.

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Abstract: Background: Microscopic colitis is a chronic inflammatory disease of the colon. There are two main sub-types: lymphocytic and collagenous colitis (CC). The incidence of CC is 1.1 to 5.2 per 100 000/year. The pathogenesis of CC is unclear despite some medications and smoking have been implicated. Patients present with insidious onset of chronic, non-bloody and watery diarrhea. Associated symptoms include fecal urgency, abdominal pain, fatigue and weight loss.

Case presentation: 68 years-old male, with controlled hypertension, under lisinopril 20mg and active tabagism since 18 years-old – 60 pack-year smoking. He went to the family doctor on January 2017 complaining with abdominal pain and intermittent episodes of watery, non-bloody diarrhea (2-3 dejections/day) starting one year ago. He had lost 6kg (6,9%) and had no fever or other associated symptoms. Physical examination revealed lower abdominal tenderness. Laboratory studies showed the absence of inflammatory markers and the abdominal ultrasound was normal.

On February, he presented to the hospital urgency service complaining with >20 dejections and abdominal pain. He had lost more 7kg (14,9% ponderal loss). Laboratory findings indicated acute kidney injury. Stool cultures, serologies to HIV, HCV, HBV and CMV, and autoantibodies were negative. Stool leukocytes were positive, so he completed 8 days of ciprofloxacin for suspected acute enterocolitis, with favourable evolution. Colonoscopy with mucosal biopsy was compatible with CC diagnosis. He started loperamide (4mg daily) with partial response. Then, was added budesonide (9mg daily, 4 weeks) with significant improvement of symptoms and weight gain.

Discussion: Microscopic colitis should be suspected in a patient with chronic diarrhea. It is important to make the differential diagnosis with irritable bowel syndrome, inflammatory bowel disease, malabsorption syndrome and chronic infections. A colonoscopy with mucosal biopsy is necessary to establish the diagnosis. The goal of therapy is to induce clinical remission (<3 stools/day or <1 watery stool/day) and includes avoid smoking and medications associated with CC. Antidiarrheals and budesonide are used in active disease. Cholestyramine and bismuth subsalicylate can be added. Anti-tumor necrosis factor agents and surgery are reserved to refractory CC. An early diagnosis is crucial. The family doctor has a very important role in diagnosis and correct referral. Nevertheless, all patients should be followed in Gastroenterology.


Title: Structured conversations: the impact of the structure of DNACPR forms on facilitating end-of-life discussions with patients and relatives.
Authors: Noam Roth, Omome Etomi, Charlotte Lau, Joanna Aithie.
Keywords: end-of-life.

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Abstract:  Background: Do Not Attempt CPR (DNACPR) forms are commonly used in hospital and community settings. However, patients are not always included in discussions over resuscitation when these forms are put in place. A new DNACPR form was introduced at the Royal Infirmary of Edinburgh, with a structure designed to encourage discussions between doctors and patients about end-of-life care. We describe an audit cycle to assess the impact of this new DNACPR form on the rates of discussions of end-of-life care.

Aim: Audit cycle to assess the impact of new DNACPR forms on the rate of DNACPR discussions.

Secondary end points include: rates of new form use, documented escalation plans, completion rates and senior counter-signatures.

Methods: 2 weeks data collection of details of DNACPR forms signed in the Acute Medical Unit (Combined Assessment Unit) of the Royal Infirmary of Edinburgh in April 2017.

Initial audit results were presented to the department with recommendations for improvement, followed by a repeat audit in May/June 2017.

Results: Number of patients recruited in original audit vs. re-audit: 35 vs. 33 Use of new form in original audit vs. re-audit: 54% vs. 84% Discussion documented in original audit vs. re-audit: 34.3% vs. 60.6% Escalation plan documented in original audit vs. re-audit: 29% vs. 64% Incomplete forms in original vs. re-audit: 17% vs. 64%

Conclusions: An increase was found in the use of new DNACPR forms following the department education following the original audit.

An increase in the use of new DNACPR forms was associated with improved rates of DNACPR discussions, escalation plans and senior counter-signatures.An increase in use of new DNACPR forms was found incidentally to be strongly associated with reduced rates of review date documentation on forms. This is likely related to the structure of new forms, where the review date was moved to the back of the form from the front.

We conclude that the structure of DNACPR forms and departmental education can have a positive impact on DNACPR discussions with patients. Both the structure of forms and regular education should be considered in facilitating behavioural change in medical practice and to encourage constructive communication between doctors and patients.


Title: Magnesium supplements in the treatment of muscle cramps - An evidence-based review.
Authors: Rita Pedro, Jéssica Perpétuo.
Keywords: magnesium; muscle cramps.

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Abstract: Introduction: Muscle cramps are a common presentation in primary health care. Although they may be associated with certain pathologies or medications, they most often occur without associated pathology, being especially common in pregnant women and the elderly. Magnesium supplements are widely marketed for various indications, namely prophylaxis of muscle cramps.

Objective: To review the available evidence on magnesium supplements in improving the frequency of muscle cramps in adults, including pregnant women.

Methodology: Research, in PUBMED and in the evidence-based medicine databases, for clinical practice guidelines (CPG), meta-analyses (MA), systematic reviews (SR) and randomized clinical trials (RCT), published between July 2007 and July 2017 in English, French, Spanish and Portuguese, using the MeSH terms "magnesium" and "cramp". To assess the quality of the studies and the strength of recommendation, it was used the Strength of Recommendation Taxonomy (SORT) from the American Family Physician.

Results: A total of 80 articles were found, of which four were selected because they met the inclusion criteria: one CPG, one MA and two SR. In adults, all studies state that there is no statistically significant difference between magnesium and placebo in reducing the frequency of muscle cramps. In pregnant women, one of the SR states that magnesium may be more effective than placebo in reducing the frequency of muscle cramps. Regarding the studies included in the MA and the other SR, some studies show benefit of magnesium when compared with placebo, in reducing the frequency of muscle cramps in pregnant women, while others do not.

Conclusions: In adults, the evidence is insufficient to recommend magnesium supplements to reduce muscle cramps frequency (strength of recommendation [SOR] B). In pregnant women, the evidence is contradictory and still inconsistent to recommend magnesium supplements to reduce muscle cramps frequency (SOR B). However, the available evidence is scarce and of reduced quality. Therefore, more RCTs, of better methodological quality, with a longer follow-up period and number of individuals, are needed to clarify the potential impact of this treatment on cramps.





Title: Heart failure diagnosis in primary care from nowadays to the future.
Authors: Sara Carmona, Maria do Rosário Novo, Carolina Resende, Paula Nunes Oliveira, Helena Oliveira, Maria Helena Febra, Teresa Libório.
Keywords: heart failure; b-type natriuretic peptide; n-terminal pro-brain natriuretic peptide; point-of-care test.

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Abstract: Background and aims: Heart failure (HF) is a common condition and a major public health problem, affecting almost 26 million people worldwide. In Portugal, its estimated prevalence is 4.36% and rises to 16.14% when considering adults over 80 years old. With populational aging is predicted that HF would affect 25% of the global population until 2030. This is a complex condition often related with multimorbidity and polypharmacy with great impact on quality of life and mortality. Therefore, HF constitutes a challenge for family doctors as health managers. With this practice report, we aim to discuss how HF is diagnosed in primary care in Portugal, and how B-type natriuretic peptide (BNP) or its N-terminal fragment (NTproBNP) use as a point-of-care test could change it in the future.

From nowadays to future practice: If all classic symptoms and signs of HF were present this would be an easy diagnosis. However, this is not always true with diagnostic tests gaining a major importance. In our practice, if HF is suspected we will support our diagnosis in echocardiography. This is undoubtedly the most helpful tool, though it isn’t immediately available in primary care as a non-acute setting. That way, we need a quick test to identify the patients at higher risk and who should go through further investigation for HF.

Recently, international guidelines are considering dosing natriuretic peptides as the first step evaluation if HF is suspected. When these biomarkers are in a normal range HF diagnosis is unlikely and could be excluded. Rapid tests for natriuretic peptides have shown to be useful distinguishing HF as the cause of acute dyspnoea in the emergency department and to accurately identify patients with left ventricular systolic dysfunction referred from general practitioners to specialized centers. Although more studies in primary care are needed, dosing BNP or NTproBNP seems to be a helpful and cost-effective measure when screening for HF, and some evidence has shown its superior accuracy when compared to the electrocardiogram.

Conclusion: In the future, the introduction of a rapid test for natriuretic peptides as a point-of-care test will improve our diagnosis accuracy, as well as, the health care provided, as we have seen in other situations like warfarin-induced hypocoagulation control based on a rapid test for International Normalized Ratio. Meanwhile, a solution could be the establishment of protocols with advanced HF centers.


Title: A different type of seizures - a case report.
Authors: Inês Ferreira Santos, Pedro Vasconcelos, Rita Bernardino Figueiredo.
Keywords: epilepsy; pseudoseizures; depression; suicidal thoughts.

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Abstract: Introduction: Pseudoseizures are psychogenic paroxysmal events, with semiological specificities, sometimes difficult to differentiate from epileptic seizures. They can coexist in a patient, which makes the differential diagnosis even more challenging.

Case Report: 18-year-old male, with a functional family, rebuilt since 2014, with feelings of rejection since that period, due to his mother's absence. Past medical history of generalized epilepsy, diagnosed in 2014 (documented activity in the electroencephalogram (EEG)) and allergic rhinitis. Since then, he was submitted to multiple hospitalizations due to non-stereotyped episodes of knowledge loss, with pleomorphic clinical manifestations, preceded by anxiety and hyperpnea, without sphincter incontinence or tongue bite, lately showing bizarre movements, with violent and arrhythmic spasms. Cranial computed tomography scans and a nuclear magnetic resonance were performed due to suspected head injury – both showed no abnormalities. Different antiepileptic regimens were tried, without success. In april 2007, he consulted his family doctor with his parents, who were worried about the increasing frequency of the episodes, aggressive motor behavior during the post-ictal period and recent mood deterioration, associated with suicidal thoughts. When questioned about it, he admitted having attempted suicide once. Objectively, he had a depressed mood and psychomotor lentification. Given the psychiatric manifestations, he was referred to the Psychiatry Emergency Room and then hospitalized. He was diagnosed with major depression and initiated sertraline 50mg and trazodone 100mg, with significant mood improvement. Based on the absence of electroencephalographic translation of the events in the video-EEG, the neurologist excluded the diagnosis of epilepsy and classified the seizures as psychogenic. The antiepileptic medication was suspended and risperidone 1mg and alprazolam 0.25mg were introduced. The frequency of the events decreased and the patient is currently on follow-up in psychiatry and family medicine consultation.

Discussion: In this case, the high frequency of the events, the bizarre and incongruent behaviors and the refractoriness to antiepileptic drugs support the diagnosis of pseudoseizures. Family doctor can play a part on considering a psychogenic etiology and possible trigger factors, such as family problems and psychiatric comorbidities, integrating them on the patient's biopsychosocial model.


Title: An occult cause for weight loss.
Authors: Ana Rita Cunha, Conceição Martins.
Keywords: weight loss; anxiety

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Abstract: A 52-year-old woman, from a nuclear family, with hypertension, anxiety, vitiligo and total hysterectomy and thyroidectomy, consulted her family physician due to dyspepsia and heartburn for 5 days. When questioned about stressor events, she denied any. There was no relevant family history except for her brother’s gastric surgery. There were no findings on physical examination. An endoscopy of the upper digestive tract was proposed, but the patient refused. Thus, an abdominal ultrasound (AU) was requested and dimeticone was prescribed. A month and a half later, she complained of heartburn, upper abdominal pain and presented with a weight loss of 12 kilograms (16.7% of the total body weight). The AU only revealed two 5mm polyps in the gallbladder. The importance of the endoscopy was reinforced and the patient agreed to do it and initiated a proton pump inhibitor after it. Four weeks later, the biopsies revealed positivity to Helicobacter pylori (Hp) and gastritis. The patient initiated the Hp eradication treatment and repeated the endoscopy two months later, which revealed intestinal metaplasia. The patient had continued to lose weight (3 more kilograms) and maintained the abdominal pain. An abdominal-pelvic computed tomography was performed and showed a renal simple cortical microcyst and no bladder polyps. The study also included a thyroid ultrasound, blood tests and cardiac exams – none with relevant alterations. Meanwhile, she accompanied her son on a primary care consultation and complained of degradation of his school performance. The presence of a stressor event, focusing on the familiar situation, was addressed again: the patient revealed she had left home because of her husband’s drinking problems. Psychological support was offered to her and the son and the patient’s husband agreed to be referred to an alcoholic center.

Discussion: The family doctor is in a privileged position to access familiar conflicts and its impact on the members’health. It is known that psychological disorders may traduce into physical symptoms. The study of the family and of its possible contribution to individual pathologies is an exclusive task of the family physicians and should always accompany the evaluation of non-specific symptoms. When needed, the family doctor should also request specific exams to exclude severe diseases, but always acting in the biopsychosocial sphere of the patient and, when possible, together with psychologist and secondary health care physicians.


Title: Establishing a First5 Group: getting started, the successes and the pitfalls.
Authors: Jodie Blackadder-Weinstein, Mike Smith.
Keywords: networking; support; newly qualified; First5; CCT

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Abstract: Background: 'The Success-Satisfaction paradox of Military General Practice trainees' by Dr Toby Holland revealed that although examination results depicted high calibre GP trainees, the study also revealed a sense of dissatisfaction with support and preparation for actually undertaking the MO role.
As part of the response to this study, a quality improvement project was undertaken to improve the support for doctors in their first five years of becoming an independent, in line with the RCGP First5 Movement.

Aims: The aim of the project was to:

1. Develop a peer support network for MOD First5s

2. Provide both CPD and social opportunities

3. Develop an MOD GP First5 representative body to ensure the groups voices are heard both within the armed forces and externally, nationally.
Method: An initial First5 conference was arranged by a recently qualified GP, and from this two representatives were elected and given a two year term to develop the network. By reviewing attendance and feedback from conferences, and a survey sent to all MOD First5s initial interventions were assessed.

Results: Positive feedback was gained from all those able to attend the 'conferences' arranged twice a year, with particularly favourable feedback on special interest lectures' (speakers or workshops not usually found on civilian GP CPD events). However, the wider First5 Survey outlined difficulty in attending face to face conferences, and a desire for more local and remote opportunities to interact.

Conclusions: Although there has been initial successes with positive feedback received from First5s, the use of lecture sharing, live event video steaming and local CPD groups must now be explored.

Title: Effective tracking for abnormal screening test results in Bateen Health Care Center, Abu Dhabi, United Arab Emirate.
Authors: Fatma Nasser, Amira Elhassan, Shamma elmazroie, Melanie Bardelosa, Eman Lahloub.
Keywords: follow-up; abnormal screening tests results.

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Abstract: Introduction & Background: Accurate and timely reporting of patient results as well as establishing a proper tracking system is an integral part of a safe and efficient practice, that will improve outcome, patient’s satisfaction and will also reduce liability. Studies have shown the adverse effects and negative outcome when results tracking has failed or got delayed. Cancer screening is only valuable and effective when the abnormal results are properly followed up. The World Health Organization (WHO) identified that the rates of test follow-up remain sub-optimal, resulting in serious lapses in patient care, delays to treatment and litigation.

We aimed to: 1- figure out the root causes for the inadequate follow-up for the abnormal test results from the system point of view 2- improve management for abnormal screening test results via developing a tracking system for our clinic

Methodology: A pre-test/ post-test study design, used to evaluate whether implementation of abnormal test result tracking process will reduce the time to follow up in Bateen health care center (2015- 2016), AD, UAE. Retrospective study for all Bateen patients with abnormal cancer screening test results (before intervention) total of 300 patients.

Intervention: A list contained all patients who did the cancer screening test for the study period (weekly updated)
- Tracking list : For patients with abnormal test results, to be recalled on the same day / or maximum in the second day (maximum in 2 days from the release of result) and to schedule an appointment with Bateen’ doctor for result discussion and management.

- Finally , we check for proper management documentation in the file; if doctor documented that the patient referred either for further investigation or to the specialist for treatment. .
- We used the two by two table and P value for calculating the results.

Results: we found that the two primary measures for the diagnostic resolution (timely follow-up appointment and effective management documentation) were improved after the intervention as follows: 98.3% and 100% respectively compared to 38.2% and 70.6% for the pre-intervention group (p<0.001)

Discussion: Our intervention significantly improved the follow up for abnormal screening test results, and factors associated with inadequate follow up are combination of both system and patient barrier.

Recommendations: Redesign the system to adopt an effective and simple tracking method for abnormal results (electronic or paper-based).


Title: Polypharmacy and potentially inappropriate medications in very old patients.
Authors: Joana Rita Bento, Denise Alexandra Velho, Célia Mata, André Rainho Dias, Bruno Pereira Carreira, David Tonelo, Patrícia Angélico, Rita Lopes Ferreira, Nadina Sousa.
Keywords: polypharmacy; potentially inappropriate medications; Beers criteria.

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Abstract:  Background: Ageing represents a worrying demographic phenomenon of modern societies. Ageing is associated with a gradual decrease in physiological reserves and increased risk of many diseases, leading to multimorbidity and polypharmacy (#5 drugs).

Multiple studies have shown a relationship between polypharmacy and potentially inappropriate medications (PIM) - medications or medication classes that should generally be avoided in patients 65 years or older because they are either ineffective or pose unnecessary high risk and a safer alternative is available.

Beers criteria are a widely used tool which enable providers to a safe prescription.

Aims: 1- To determine the prevalence of polypharmacy and PIMs in very old patients (# 80 years) of a Portuguese Family Health Unit (FHU), applying Updated 2012 Beers Criteria by the American Geriatric Society; 2 - To verify if there is an association between polypharmacy and PIMs.

Methods: Cross-sectional study. Population: all elderly subjects aged # 80 years old registered in the FHU (n=419). Exclusion criterion: patients without any prescription by one of the FHU’s doctors during the chosen period of data collection. Electronic medical records were assessed to collect age, sex, number of chronic diseases, number of chronic medications and PIMs prescribed between September 2016 and August 2017. Software: Excel 2007® and SPSS 21.0. Test: Chi-squared test (l.s. 5%).

Results: 347 patients were included in the sample, with a mean age of 87.7 years (SD = 3.7), 63.1 % being female. The mean number of chronic diseases per patient was 4.9 (SD = 2.7). Polypharmacy was found in 74.9% of the subjects, with a mean number of drugs per person of 6.6 (SD=3.1). A total of 182 (52.4 %) subjects were prescribed at least one PIM. Benzodiazepines and nonsteroidal anti-inflammatory drugs were the drug classes more frequently prescribed. We observed a statistically significant association between polypharmacy and PIMs (p <0.001).

Discussion: Medication toxic effects and drug related problems can have profound medical and safety consequences in older patients. The obtained results evidence a concerning prevalence of polypharmacy and PIMs. This study triggered an urgent quality improvement cycle with future clinical audits in our FHU.