Patient consultations during SARS-CoV-2 pandemic: a mixed-method cross-sectional study in 16 European countries.

INTRODUCTION: Remote consultations help reduce contact between people and prevent cross-contamination. Little is known about the changes in consultation in European rural primary care during the SARS-CoV-2 (COVID-19) pandemic. The purpose of this mixed-methods cross-sectional study was to find out more about the effects of the pandemic on changes in patient consultations in European rural primary care. METHODS: A key informant survey from 16 member countries of the European Rural and Isolated Practitioners Association (EURIPA) was undertaken using a self-developed questionnaire. The steering committee of this project, called EURIPA Covid-19 study, developed a semi-structured questionnaire with 68 questions, 21 of which included free-text comments. Proportions were calculated for dichotomized or categorized data, and means were calculated for continuous data. Multivariate analysis by logistic regression model was used to assess the association of multiple variables. RESULTS: A total of 406 questionnaires from primary care providers (PCPs) in 16 European countries were collected; 245 respondents (60.5%) were females, 152 PCPs were rural (37.5%), 124 semi-rural (30.5%). Mean age of the respondents was 45.9 years (standard deviation (SD) 11.30) while mean seniority (length of experience) was 18.2 years (SD 11.6). A total of 381 (93.8%) respondents were medical doctors. Significant differences were found between countries in adopting alternative arrangements to face-to-face consultation: remote teleconsultation is well appreciated by both healthcare professionals and patients, but the most common way of remote consultation remains telephone consultation. A factor significantly inversely associated with the adoption of video consultation was the seniority of the PCP (odds ratio 1.19, 95% confidence interval 1.02-1.40, p=0.03). CONCLUSION: Telephone consultation is the most common form of remote consultation. The adoption of video-consultation is inversely related to the seniority of the informants.

Abdominal Cutaneous Nerve Entrapment Syndrome: The Cause of Localized Abdominal Pain in a Young Pregnant Woman.

BACKGROUND: Despite the broad differential diagnosis in any patient referring with symptoms involving the chest or abdomen, a small number of conditions overshadow the rest by their probability. Chest and abdominal wall pain continues to constitute a common and expensive overlooked source of pain of unknown cause. In particular, cutaneous nerve entrapment syndrome is commonly encountered but not easily diagnosed unless its specific symptoms are sought and the precise physical examination undertaken. CASE REPORT: A primigravida woman with unbearable abdominal pain was referred repeatedly seeking a solution for her suffering. Numerous laboratory and imaging studies were employed in order to elucidate the cause of her condition. After numerous visits and unnecessary delay, the diagnosis was finally made by a physician fully versed in the field of torso wall pain. The focused physical examination disclosed abdominal cutaneous nerve entrapment syndrome as the diagnosis, and anesthetic infiltration led to immediate alleviation of her pain. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Cutaneous nerve entrapment is a common cause of abdominal pain that is reached on the basis of thorough history and physical examination alone. Knowledge dissemination of the various torso wall syndromes is imperative for prompt delivery of suitable care. All emergency physicians should be fully aware of this entity because the diagnosis is based solely on physical examination, and immediate relief can be provided in the framework of the first visit. Wider recognition of this syndrome will promise that such mishaps are not repeated in the future.

Diaper Slit Perineal Bag Urine Sampling.

OBJECTIVE: Many indications justifiably drive the pediatrician to request a urine sample in order to assess the health status of the incontinent baby or infant. Urine collection by means of an adhesive perineal bag is the most widely used in children who do not control urine emission, despite its inaccurate reflection of bacteriuria. We suggest a novel technique to immediately visualize the micturition event upon occurrence, in attempt to shorten waiting times and exhausting checking and rechecking opaque diapers in order to determine whether the desired sample has finally been delivered. METHODS: The perineal urine collection bag is pulled through a vertical slit created in the front of the disposable diaper. The bag is now visible at all times. RESULTS: In general, waiting times appear shortened since the implementation of this practice. Since the adoption of this technique at a number of our clinics, we have not experienced bag displacement as was previously experienced. Forgoing the need to manipulate the diaper and repeatedly awakening irritable infants was gladly welcomed by parents. CONCLUSIONS: Widespread adoption of the diaper slit technique seems a promising procedure enhancing comfort and facilitating the process of obtaining a urine sample in the incontinent child. Assumptions that this procedure actually shortens waiting times and raises the success rates of sample retrieval remain to be proven by formal comparative trials.

Revisiting the Jewish Ethical Approach Toward Perimortem Cesarean Section in Light of Emerging Medical Evidence.

BACKGROUND: Maternal cardiac arrest during gestation constitutes a devastating event. Training and anticipant preparedness for prompt action in such cases may save the lives of both the woman and her fetus. OBJECTIVES: To address a previous Jewish guideline that a woman in advanced pregnancy should not undergo any medical procedure to save the fetus until her condition is stabilized. METHODS: Current evidence on perimortal cesarean section shows that immediate section during resuscitation provides restoration of the integrity of the mother's vascular compartment and increases her probability of survival. We analyzed Jewish scriptures from the Talmud and verdicts of the oral law and revealed that the Jewish ethical approach toward late gestational resuscitation was discouraged since it may jeopardize the mother. RESULTS: We discuss the pertinent Jewish principles and their application in light of emerging scientific literature on this topic. An example case that led to an early perimortem cesarean delivery and brought about a gratifying, albeit only partially satisfying outcome, is presented, albeit with only a partially satisfying outcome. The arguments that were raised are relevant to such cases and suggest that previous judgments should be reconsidered. CONCLUSIONS: The Jewish perspective can guide medical personnel to modify and adapt the concrete rules to diverse clinical scenarios in light of current medical knowledge. With scientific data showing that both mother and fetus can prosper from immediate surgical extrication of the baby during resuscitation of the advanced pregnant woman, these morals should dictate training and practice in urgent perimortal cesarean sections whenever feasible.

Open Microcomedone Extraction Facilitated by Polarized Dermoscopy.

Microcomedonal lesions can be aesthetically and psychologically displeasing. The burden of comedones increases when considering their frequency and demand for time-consuming attention. The objective of the current study was to describe a novel technique to facilitate open microcomedone extraction. The instrumentation used includes smartphone photography with dermatoscopy. The dermatoscope is an effective tool for diagnosing a broad range of dermatologic conditions. The polarized dermatoscope can facilitate execution of cutaneous procedures whenever magnification and optimal illumination are necessary. Its connection to a smartphone with a unique adapter enabled single-handed examination of microcomedones. Under magnification with this unit, the involved lesions are photographed to clearly demonstrate the condition and achieve informed consent. The complete procedure can be recorded on video for documentation. In this case, four separate lesions of the left auricle of a young man were treated using direct pressure extraction. The procedure undertaken was rapid, convenient, and completed without any adverse sequelae. This procedure is recommended for similar cases using the dermatoscope, which does not require additional specific training and is readily available at no extra cost. This technique could be used in various dermatologic conditions.

[THE HUMAN CHAMELEON--BOMBARDED].

A new attitude recently raised in the literature emphasizing the role of the family in the care of the patient introduces a novel paradigm of family presence during resuscitation, which continues to be a debatable issue without widespread implementation. Can the same recommendations rooted at medical centers be extrapolated to the traumatic scene where a physician is called to treat his own community members? In this paper the scenario presented depicts a family physician called to treat terrorist victims of his own community overwhelmed by dilemmas including ethical considerations. He is subjected to stress and strain that seem beyond his capacity. The physician in rural settings may be placed in situations that confront challenges demanding metamorphosis in order to answer unexpected needs towards which he has not been fully trained. Despite the hardships involved, withstanding such situations can lead to profound satisfaction.

Jewish holidays and their associated medical risks.

Religiosity is inherent in human cultures. Being different in many aspects, all have rules regarding appropriate behavior and rituals. Celebrations of social events and of holidays prevail in all major religions. These include code of dress, prayers, special food and activities which may have negative health implications. The Jewish religion is 'blessed' with an abundance of holidays each with its unique health implications. In this paper we provide an outline of the character of these festivals and possible medical repercussions on those celebrating them. Observant members of the Jewish religion and teams treating this population should be knowledgeable of potentially associated risks. Pre-holiday periods should be specifically targeted for educational and preventive activity in order diminish injury or morbidity.

[Safe quadruplet gestation following peripartum discectomy for massive disc prolapse].

INTRODUCTION: We would Like to present a rare case of multiple gestation following a severe event of spinal cord morbidity during a previous singleton gestation. The medical literature carries a paucity of evidence regarding the future fate of pregnancies following gestational induced intervertebral disc prolapse. CASE HISTORY: A 21 year old mother delivered a healthy boy after unbearable back pain. She subsequently developed urinary retention with laxity of the anal sphincter and underwent urgent L5-S1 discectomy. Following in vitro fertilization for infertility she conceived and was warned of the dangers of a gestation with quadruplets. The parents decided to continue the gestation regularly without intervention despite possible complications. At 31 weeks of gestation the mother delivered four normal male babies, each weighing over 1200 grams after a normal (supervised) pregnancy devoid of any back symptoms. This case demonstrates a novel clinical scenario of hitherto unreported major challenges to an established vulnerable vertebral column. DISCUSSION: To the best of our knowledge this is the first report of a multiple gestation following severe spinal column pathology demanding surgical intervention in order to prevent long term handicap. We could not even locate a series of singleton gestations following such a clinical scenario. The favorable outcome observed in this case is very encouraging and can serve to reassure potential mothers who have experienced a similar previous episode as demonstrated here. CONCLUSION: Special caution must be taken when consulting pregnant patients. From this case history we may learn that precautions such as indefinite contraception after a previous incident of massive disc prolapse may be widely unnecessary.

Health ramifications of the Gush Katif evacuation.

BACKGROUND: Following the 2005 evacuation of Gush Katif, a community of Jewish settlements located in the greater Gaza Strip, many evacuees reported a deterioration in their health status. OBJECTIVES: To determine if and to what degree the evacuation of Gush Katif caused a worsening in the health status of the evacuees. METHODS: In this retrospective cohort study we assessed the medical records of 2962 evacuees for changes in prevalence of diabetes, hypertension and ischemic heart disease in the period beginning 1 year before and ending 5 years after the evacuation. The findings were compared to those for the general israeli population. A questionnaire was distributed to 64 individuals to assess lifestyle and social change. RESULTS: An increase in diabetes and hypertension was found in men aged 45-64. The prevalence of diabetes mellitus in the 45-54 male group rose from 8.7% in 2004 to 12.6% in 2007 to 18.7% in 2010; in the 55-64 age group it rose from 24.6% in 2004 to 29.9% in 2007 to 32.9% in 2010. Hypertension in 45-64 year old men rose from 27.1% in 2004 to 35.12% in 2010. The increases in diabetes were significant and higher than those in the general population. The increases in hypertension were of similar magnitude. The prevalence of heart disease did not change and is similar to that in the general population. The questionnaire sample showed an increase in depression and overweight. CONCLUSIONS: The Gush Katif evacuation appears to be associated with increased morbidity of chronic disease. This may be attributed to any of several mechanisms, with unemployment, depression, inactivity and overweight playing significant roles. Preventive medical interventions and measures should be employed to screen and treat this population which underwent a major stressful event and as a result seem at greater risk than their peers.

Abdominal wall ischemic fasciitis associated with a torso brace in a young girl.

We describe a rare case of ischemic fasciitis of the abdominal wall in a child with scoliosis. The fasciitis was apparently caused by the constant pressure exerted by her torso brace. Clinicians should be alert to the possibility of mechanical factors in the etiology of ischemic fasciitis.

Significance of the tethered maxillary frenulum: a questionnaire-based observational cohort study.

BACKGROUND: The clinical significance of lip-tie, or a tethered maxillary frenulum, remains under debate. Clinicians and parents are often perplexed when deciding whether procedures available to relieve a seemingly tight or severe maxillary frenulum are needed. PURPOSE: No previous studies have assessed the consequences of not subjecting a tethered maxillary frenulum in newborns to surgical intervention. This study aimed to contribute the first prospective trial on this topic with a relatively extended followup of these newborn infants. METHODS: This prospective observational questionnaire-based cohort trial was performed in a community setting and aimed to determine whether lip-tie is associated with an increased likelihood of eventual feeding or oral disorders. RESULTS: The convenience sample comprised of 61 consecutively arriving infants with concomitant tethered frenula who were treated at the clinic for various reasons. This cohort was compared with a random sample of 66 age-matched children for a mean follow-up period of 6.42 years. Infants undergoing oropharyngeal procedures were excluded. Awareness of a deviation in oral structures was reported by 18% of the study group versus 0% of the controls. Mothers participating in the study group (24.6%) less frequently recalled painful nipples or discomfort during breastfeeding than those in the control group (47.0%) (P<0.01). There were no intergroup differences in other types of feeding difficulty, dental hygiene, pronunciation, or speech development. CONCLUSION: Our findings suggest that a tethered labial frenulum is not associated with an increase in breastfeeding disturbances or oral disorders. These data encourage clinicians to question the need to intervene in cases of tethered maxillary frenula.

Periodic fever responds to vitamin B12 treatment.

UNLABELLED: Periodic fever of childhood is a group of diseases that cause repeated febrile illnesses with various associated symptoms. In our article, we present the case of a 6-year-old girl with unusual appearance of periodic fever syndrome. Our patient suffered from repeated episodes of high fever from the age of 2 years old. Each episode usually lasted 24-48 h, the interval between events was 1-3 weeks long. During high fever episodes the child usually felt well, without associated accompanying complaints. As a rule, the physical examination did not reveal any pathologic finding explaining the fever. During the 4 years of follow-up the patient sustained treatment attempts with prednisone for a number of months and half a year with colchicine without any response. We considered treatment with sublingual tablets of vitamin B12 (VIT B12). Beyond all expectation, we witnessed complete resolution of attacks during the first 2 months following treatment. After a long episode-free period, the parents withheld the treatment on their own accord, and in a short time the disease recurred. We advised to renew the treatment with VIT B12, and during approximately half year of follow-up there were no recurrences of periodic fever. CONCLUSION: we believe that our observation raises interest in systematic evaluation of the therapeutic role of VIT B12 as a treatment option for disorders of the periodic fever spectrum.

The new kid on the block in physical diagnosis? Introducing digital microscopy.

Emerging microprocessor technology has revolutionized all aspects of life in the modern era. Feats previously achieved through sophisticated, cumbersome and expensive devices are currently both commonplace and feasible with convenient instruments available at low-cost. Body surface inspection can prove very challenging when seeking minute alterations of anatomy and miniature inflicting culprits. USB (universal serial bus) dermatoscopy (UD) is the most economical and widespread technique widely utilized in industry and even lay use but inadeqautely addressed in the field of medicine. This manuscript provides a preliminary exposure of UD to those unfamiliar with this technique and demonstrates its merits improving patient care. UD constitutes an ideal method to magnify, up to over 100 fold, minute detail and project images on a screen of choice, be it a laptop, tablet or standard smartphone. Clinical practice, especially in rural areas, has much to gain from a device that can expose illusive clinical detail that is imperceptible by the naked eye. The basis of the technique is described and genuine cases where it was utilized are shared. Personal experience with this technique demonstrates that employing ample magnification and thorough illumination facilitates reaching the correct diagnosis whenever physical examination of the superficial body surface is necessary. Body regions amenable for improved visualization with this method extend from scalp hair, skin and ocular structures, all the way to the anal sphincter. The objective of this paper is to familiarize physicians with the advantages of digital microscopy through numerous clinical illustrations, as: characterization and surveillance of lesions, sores, cutaneous and corneal foreign bodies, painful conditions of the nipple, hematomas retained sutures, secretions and purulent lesions. This introduction is hoped to arouse enthusiasm towards digital microscopy and encourage its adoption into routine practice.

Post Circumcision Corona Obliteration.

OBJECTIVE: Abnormal healing after neonatal ritual circumcision is a source of significant concern to patients' parents and their caregivers. This report presents a series of male infants who underwent ritual circumcision and subsequently developed obliteration of the normally distinct structure of the corona. METHODS: We report a case series of infants recruited from the community and a medical center. The compulsory inclusion criterion was absence of the normal landmarks of the glans penis with confirmed integrity of normal male genitalia. Illustrative cases are presented. The possible pathogenetic mechanisms leading to this condition are discussed. A literature search was conducted to discern whether this phenomenon has ever been previously reported. RESULTS: The eight cases we diagnosed were all otherwise normal. In one case, where we discovered use of an active substance on the circumcision wound, the condition persisted for an extended period but it resolved completely by 15 months of age. In all but one of the subjects the condition was transient and resolved over time. We could not reveal any previous publication on this topic. DISCUSSION: This noteworthy complication of circumcision raises debate whether it was previously existent, though unreported or a novel phenomenon. We postulate that contributing factors leading to tissue injury may possibly be injured tissue exposure to irritating substances, vascular compromise, the technique chosen to control bleeding or an idiosyncratic response to tissue trauma. More attention to the occurrence of this phenomenon is compulsory to collect more data and learn of its incidence and eventual impact. CONCLUSIONS: Obliteration of the corona, constitutes an unreported, rare albeit significant complication following circumcision. We recommend refraining from potentially inciting factors leading to this undesirable condition. More extensive experience with this disorder may enable us to employ preventive measures to eliminate it or at least provide reassurance wherever possible.