Primary care indicators for disease burden, monitoring and surveillance of COVID-19 in 31 European countries: Eurodata Study.

BACKGROUND: During the COVID-19 pandemic, the majority of patients received ambulatory treatment, highlighting the importance of primary health care (PHC). However, there is limited knowledge regarding PHC workload in Europe during this period. The utilization of COVID-19 PHC indicators could facilitate the efficient monitoring and coordination of the pandemic response. The objective of this study is to describe PHC indicators for disease surveillance and monitoring of COVID-19's impact in Europe. METHODS: Descriptive, cross-sectional study employing data obtained through a semi-structured ad hoc questionnaire, which was collectively agreed upon by all participants. The study encompasses PHC settings in 31 European countries from March 2020 to August 2021. Key-informants from each country answered the questionnaire. Main outcome: the identification of any indicator used to describe PHC COVID-19 activity. RESULTS: Out of the 31 countries surveyed, data on PHC information were obtained from 14. The principal indicators were: total number of cases within PHC (Belarus, Cyprus, Italy, Romania and Spain), number of follow-up cases (Croatia, Cyprus, Finland, Spain and Turkey), GP's COVID-19 tests referrals (Poland), proportion of COVID-19 cases among respiratory illnesses consultations (Norway and France), sick leaves issued by GPs (Romania and Spain) and examination and complementary tests (Cyprus). All COVID-19 cases were attended in PHC in Belarus and Italy. CONCLUSIONS: The COVID-19 pandemic exposes a crucial deficiency in preparedness for infectious diseases in European health systems highlighting the inconsistent recording of indicators within PHC organizations. PHC standardized indicators and public data accessibility are urgently needed, conforming the foundation for an effective European-level health services response framework against future pandemics.

Effectiveness of patients' involvement in a medical and nursing pain education programme: a protocol for an open-label randomised controlled trial including qualitative data.

INTRODUCTION: Pain is a multidimensional experience that varies among individuals and has a significant impact on their health. A biopsychosocial approach is recommended for effective pain management; however, health professionals' education is weak on this issue. Patient involvement is a promising didactic methodology in developing a more holistic perspective, however there is a lack of reliable evidence on this topic. The aim of the present study is to evaluate the effectiveness of patient involvement in pain education in undergraduate medicine and nursing students. METHODS AND ANALYSIS: An open-label randomised controlled trial including qualitative data will be conducted. After an introductory lesson, each student will be randomly assigned to the intervention group, which includes an educational session conducted by a patient-partner along with an educator, or to the control group in which the session is exclusively conducted by an educator. Both sessions will be carried out according to the Case-Based Learning approach. Primary outcomes will be students' knowledge, attitudes, opinions and beliefs about pain management, whereas the secondary outcome will be students' satisfaction. The Pain Knowledge and Attitudes (PAK) and Chronic Pain Myth Scale (CPMS) will be administered preintervention and postintervention to measure primary outcomes. Students' satisfaction will be measured by a questionnaire at the end of the session. Two focus groups will be conducted to evaluate non-quantifiable aspects of learning. ETHICS AND DISSEMINATION: The protocol of this study was approved by the independent Area Vasta Emilia Nord ethics committee.Adherence to The Declaration of Helsinki and Good Clinical Practice will ensure that the rights, safety and well-being of the participants in the study are safeguarded, as well as data reliability. The results will be disseminated through scientific publications and used to improve the educational offer. A version of the anonymised data set will be released for public access. TRIAL REGISTRATION: Trial was not registered on ClinicalTrials.gov as the interventions being compared only concern educational programmes and the outcomes considered do not refer to any clinical dimension.

[Home management of Covid-19 pneumonia in the early phases of the pandemic: analysis of real-life data of General Practitioners in the Province of Modena from the MAGMA study.] / Gestione domiciliare dei pazienti con polmonite da Covid-19 nelle fasi precoci della pandemia: analisi dei dati real-life della Medicina Generale della Provincia di Modena dallo studio MAGMA.

Primary care management of Covid-19 pneumonia in the Province of Modena in the early phases of the pandemic: data integration from MAGMA study. Retrospective study on patients affected of Covid-19 and followed by General Practitioner from March 2020 to April 2021. 5340 patients were studied, 27% of them developed pneumoniae. Among these, most of them were managed entirely at home with an elevated intensity of care. Daily remote monitoring and home visits, together with a personalized pharmacological treatment, especially for the most severe forms, appeared to be the most effective interventions in reducing hospitalizations.

[Top 4 Research Studies of the month for Italian Primary Care Physicians: November 2023.] / La Top 4 di novembre 2023. Gli studi clinici che vale la pena conoscere se lavori nelle cure primarie in Italia.

This monthly article provides a collection of summaries of the most relevant studies identified as POEMs (patient-oriented evidence that matters) for Italian primary care physicians. 1) Based on efficacy, safety, and cost, a regimen of terbinafine 250 mg once daily for 12 weeks, followed by a 12-week period of no therapy, and then a 4-week booster of terbinafine 250 mg is preferred for onychomycosis in adults for the outcome of complete cure at 1 year. 2) A high-quality randomized trial found that standard-course antibiotic therapy for children with uncomplicated urinary tract infection was superior to short-course therapy. However, the number needed to treat of 28 suggests that offering short-course therapy is not unreasonable, especially if there is good follow-up in the subsequent weeks. 3) An updated guideline of the American College of Physicians on screening of colorectal cancer adds 2 new recommendations. One is to consider not screening patients aged 45 to 49 years. The other recommendation is against screening using stool Dna, computed tomography colonography, capsule endoscopy, urine, or serum screening tests for colorectal cancer. 4) The US Preventive Services Task Force found additional evidence on the benefit of folic acid supplementation for preventing neural tube defects. Since the critical period starts at least 1 month before conception, the task force recommends a daily supplement of 0.4 mg to 0.8 mg folic acid for all women who plan to or could become pregnant.

The role of primary health care in long-term care facilities during the COVID-19 pandemic in 30 European countries: a retrospective descriptive study (Eurodata study).

BACKGROUND AND AIM: Primary health care (PHC) supported long-term care facilities (LTCFs) in attending COVID-19 patients. The aim of this study is to describe the role of PHC in LTCFs in Europe during the early phase of the pandemic. METHODS: Retrospective descriptive study from 30 European countries using data from September 2020 collected with an ad hoc semi-structured questionnaire. Related variables are SARS-CoV-2 testing, contact tracing, follow-up, additional testing, and patient care. RESULTS: Twenty-six out of the 30 European countries had PHC involvement in LTCFs during the COVID-19 pandemic. PHC participated in initial medical care in 22 countries, while, in 15, PHC was responsible for SARS-CoV-2 test along with other institutions. Supervision of individuals in isolation was carried out mostly by LTCF staff, but physical examination or symptom's follow-up was performed mainly by PHC. CONCLUSION: PHC has participated in COVID-19 pandemic assistance in LTCFs in coordination with LTCF staff, public health officers, and hospitals.

Evaluation of an interprofessional education intervention in partnership with patient educators.

BACKGROUND AND AIM: Patient involvement in interprofessional education is a novel approach to building collaborative and empathic skills in students. However, this area of teaching is lacking in rigorous studies. The project aimed to evaluate whether an interprofessional education intervention in partnership with patient educators (IPE-PE) would increase readiness for interprofessional learning and empathy in health sciences students. METHODS: This is the report of a didactic innovation project. Participants included 310 undergraduate health sciences students who took part in an IPE-PE intervention. Data were collected before and after the training, using the Readiness for Interprofessional Learning Scale (RIPLS) and the Jefferson Scale of Empathy-Health Professions Student version (JSE-HPS). Only at the end of the intervention, a data collection form was administered to explore the value of the patient educator in the training and to investigate the socio-demographic variables. RESULTS: The mean age of participants was 21±3.2 SD years and 76% were female. A paired t-test showed significant changes from before to after the IPE-PE in the mean total RIPLS score (42.7±5.8 SD vs 44.62±5.9 SD, P<0.001) and the mean total JSE-HPS score (112.7±12.5 SD vs 116.03±12.8 SD, P<0.001).            Conclusions: Our students reported that IPE-PE had helped them to become more effective healthcare team members, to think positively about other professionals, and to gain empathic understanding of the perspective of the person being cared for. The results of the project confirm that the intervention promoted the development of empathy, fostering a better understanding of the patient-centred perspective.

[Focusing on patient-oriented evidence that matters: a practical approach to keeping up with new research.] / Evidenze mediche orientate al paziente: un approccio pratico per rimanere aggiornati sugli studi che vale la pena conoscere.

One of the challenges of medical practice, especially primary care because of its breadth, is keeping up with the latest research findings. As physicians, how can we select, among hundreds of thousands of research studies published each year, those worth knowing about? Since 1996, a group of American primary care physicians have been systematically reviewing over 100 journals every month to identify new Patient-Oriented Evidence that Matters (POEMs). To be a POEM, a research study must have the potential to change clinical practice by addressing hard, patient-oriented outcomes, such as mortality, intensity or duration of symptoms, or quality of life, as opposed to disease-oriented (surrogate) outcomes, such as laboratory parameters. In addition, it must be methodologically valid, i.e., reasonably free of bias, with its validity evaluated through objective criteria by experts in evidence-based medicine with no conflicts of interest with the industry. To be useful at the point of care, these studies must be easy to retrieve and require little work to review. Starting from this issue, a selection of POEMs most likely to change and improve Italian primary care practice will be published monthly in Recenti Progressi in Medicina as brief evidence summaries. In addition, yearly, we will present an article summarizing the 20 most important research studies for primary care of the previous year.

[Making change: the new principles of the World organization of general medicine (Wonca 2022) and territorial medicine in Italy.] / Realizzare il cambiamento: i nuovi princìpi dell'organizzazione europea della medicina generale (Wonca Europe 2022) e la medicina territoriale in Italia.

The new european declaration "Core values and principles of general practice and family medicine" (Wonca Europe 2022) has been recently issued: which contributions can it provide to the discussion on the future of primary health medicine? And what challenges and changes would it impose in its application to the contexts of medical training, care services and clinical research in Italy? We analyse here the seven principles and values of the new declaration: 1) person-centred care; 2) continuity of care; 3) cooperation in care; 4) community-oriented care; 5) equity in care; 6) science-oriented care; 7) professionalism in care; and through them we reflect on the announced reforms of primary health care (Phc) policy. Indeed, these provide an important basis for a critical discussion regarding the reform of the primary care model, the evolution of the medical training pathway (pre- and post-graduate and therefore towards an adjustment of the specialty pathway of future general practitioners) and research Phc. Considering that the Phc health policies are experiencing a condition of permanent and apparently uncontrollable change, it is well to ask ourselves how and if these values-principles, which are considered fundamental at an international level, will be able to come to life in order to build a new therapeutic trust, specific to general practice and family medicine, both in the professional and disciplinary sphere.

[Top 5 Research Studies of the month for Italian Primary Care Physicians: October 2023.] / La Top 5 di ottobre 2023. Gli studi clinici che vale la pena conoscere se lavori nelle cure primarie in Italia.

This monthly article provides a selection of summaries of the most relevant studies identified as POEMs (patient-oriented evidence that matters) for Italian primary care physicians. Amoxicillin is no more likely to cause a rash than any other antibiotic in children with infectious mononucleosis. According to a good quality systematic review and network meta-analysis, only a small number of randomized controlled trials, disappointing in overall quality, suggest that for managing neuropsychiatric symptoms in adults with dementia, risperidone has the best balance of effectiveness and adverse effects. In a rigorously conducted double-blind randomized controlled trial, adults with acute low back or neck pain treated with opioids had no benefit in pain relief as those treated with placebo. In a large study of more than 21,000 participants aged 60 to 84 years, taking 60,000 IU vitamin D each month slightly reduced their likelihood of experiencing a major cardiovascular event (number needed to treat = 172 over 5 years). A single screening colonoscopy had higher rates of participation than 5 years of fecal occult blood testing in a high-quality study in which patients were offered free screening with these two methods (84% vs 73%; p<0.001).

Strengths, Weaknesses, Opportunities, and Threats Analysis of the Use of Digital Health Technologies in Primary Health Care in the Sub-Saharan African Region: Qualitative Study.

BACKGROUND: Digital health technologies (DHTs) have become increasingly commonplace as a means of delivering primary care. While DHTs have been postulated to reduce inequalities, increase access, and strengthen health systems, how the implementation of DHTs has been realized in the sub-Saharan Africa (SSA) health care environment remains inadequately explored. OBJECTIVE: This study aims to capture the multidisciplinary experiences of primary care professionals using DHTs to explore the strengths and weaknesses, as well as opportunities and threats, regarding the implementation and use of DHTs in SSA primary care settings. METHODS: A combination of qualitative approaches was adopted (ie, focus groups and semistructured interviews). Participants were recruited through the African Forum for Primary Care and researchers' contact networks using convenience sampling and included if having experience with digital technologies in primary health care in SSA. Focus and interviews were conducted, respectively, in November 2021 and January-March 2022. Topic guides were used to cover relevant topics in the interviews, using the strengths, weaknesses, opportunities, and threats framework. Transcripts were compiled verbatim and systematically reviewed by 2 independent reviewers using framework analysis to identify emerging themes. The COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist was used to ensure the study met the recommended standards of qualitative data reporting. RESULTS: A total of 33 participants participated in the study (n=13 and n=23 in the interviews and in focus groups, respectively; n=3 participants participated in both). The strengths of using DHTs ranged from improving access to care, supporting the continuity of care, and increasing care satisfaction and trust to greater collaboration, enabling safer decision-making, and hastening progress toward universal health coverage. Weaknesses included poor digital literacy, health inequalities, lack of human resources, inadequate training, lack of basic infrastructure and equipment, and poor coordination when implementing DHTs. DHTs were perceived as an opportunity to improve patient digital literacy, increase equity, promote more patient-centric design in upcoming DHTs, streamline expenditure, and provide a means to learn international best practices. Threats identified include the lack of buy-in from both patients and providers, insufficient human resources and local capacity, inadequate governmental support, overly restrictive regulations, and a lack of focus on cybersecurity and data protection. CONCLUSIONS: The research highlights the complex challenges of implementing DHTs in the SSA context as a fast-moving health delivery modality, as well as the need for multistakeholder involvement. Future research should explore the nuances of these findings across different technologies and settings in the SSA region and implications on health and health care equity, capitalizing on mixed-methods research, including the use of real-world quantitative data to understand patient health needs. The promise of digital health will only be realized when informed by studies that incorporate patient perspective at every stage of the research cycle.

The effects of primary care monitoring strategies on COVID-19 related hospitalisation and mortality: a retrospective electronic medical records review in a northern Italian province, the MAGMA study.

BACKGROUND: Most symptomatic SARS-CoV-2 infections produce mild to moderate symptoms. Although most patients are managed in the outpatient setting, little is known about the effect of general practitioners' (GP) management strategies on the outcomes of COVID-19 outpatients in Italy. OBJECTIVES: Describe the management of Italian GPs of SARS-CoV-2 infected adult patients and explore whether GP active care and monitoring are associated with reducing hospitalisation and death. METHODS: Retrospective observational study of SARS-CoV-2 infected adult outpatients managed by GPs in Modena (Italy) from March 2020 to April 2021. Information on management and monitoring strategies, patients' socio-demographic characteristics, comorbidities, and outcomes (hospitalisation and death due to COVID-19) were retrieved through an electronic medical record review and analysed descriptively and through multiple logistic regression. RESULTS: Out of the 5340 patients from 46 GPs included in the study, 3014 (56%) received remote monitoring, and 840 (16%) had at least one home visit. More than 85% of severe or critical patients were actively monitored (73% daily) and 52% were visited at home. Changes over time in patients' therapeutic management were observed in concordance with the guidelines' release. Active daily remote monitoring and home visits were strongly associated with reduced hospitalisation rate (OR 0.52, 95% CI 0.33-0.80 and OR 0.50, 95% CI 0.33-0.78 respectively). CONCLUSION: GPs effectively managed an increasing number of outpatients during the first waves of the pandemic. Active monitoring and home visits were associated with reduced hospitalisation in COVID-19 outpatients.

Clinical pathway of COVID-19 patients in primary health care in 30 European countries: Eurodata study.

BACKGROUND: Most COVID-19 patients were treated in primary health care (PHC) in Europe. OBJECTIVES: To demonstrate the scope of PHC workflow during the COVID-19 pandemic emphasising similarities and differences of patient's clinical pathways in Europe. METHODS: Descriptive, cross-sectional study with data acquired through a semi-structured questionnaire in PHC in 30 European countries, created ad hoc and agreed upon among all researchers who participated in the study. GPs from each country answered the approved questionnaire. Main variable: PHC COVID-19 acute clinical pathway. All variables were collected from each country as of September 2020. RESULTS: COVID-19 clinics in PHC facilities were organised in 8/30. Case detection and testing were performed in PHC in 27/30 countries. RT-PCR and lateral flow tests were performed in PHC in 23/30, free of charge with a medical prescription. Contact tracing was performed mainly by public health authorities. Mandatory isolation ranged from 5 to 14 days. Sick leave certification was given exclusively by GPs in 21/30 countries. Patient hotels or other resources to isolate patients were available in 12/30. Follow-up to monitor the symptoms and/or new complementary tests was made mainly by phone call (27/30). Chest X-ray and phlebotomy were performed in PHC in 18/30 and 23/30 countries, respectively. Oxygen and low-molecular-weight heparin were available in PHC (21/30). CONCLUSION: In Europe PHC participated in many steps to diagnose, treat and monitor COVID-19 patients. Differences among countries might be addressed at European level for the management of future pandemics.

[How are future family doctors in Italy trained? Pilot descriptive study of Postgraduate Training in General Practice.] / Come si formano i futuri medici di medicina generale in Italia? Studio pilota descrittivo di comparazione dei Corsi di formazione specifica in medicina generale.

INTRODUCTION: General practitioner (GP) training programme involves a complex process. In Italy, unlike in other European countries, there is no national core curriculum for the training of GPs and the three-year specific training course in General Medicine (CSFMG) is not equated as a proper specialty. Furthermore, the quality of the CFSMGs is poorly investigated and data are difficult to find/fragment. The aim of this study is to describe and compare GP tranining from two pilot regions (Lombardy and Lazio). METHODS: The study analysed the white and grey literature. For data collection a descriptive grid was created using the characteristics foreseen by current legislation as comparison indicators; the information came exclusively from official and public written data. RESULTS: The analysis reports indicators: structural-organisational; theoretical activity; practical activity; research/guided study; final thesis. DISCUSSION: The most evident fact that emerges is the lack of available (show the gap), public and official information on the GP training, therefore the description and comparison of the basic indicators in the pilot Regions suffers. A learning model based more on minimum time requirements (time-based learning) than on competences to be acquired (competencies-based learning) is evident. Furthermore, the professional/academic profiles of the lecturers are not available and thus comparable; finally, no information on the training methodologies of the frontal/research sessions can be found. CONCLUSIONS: The limitation to only two Regions and the lack of available data do not allow a comprehensive assessment and it would be useful to extend the study on a national scale. However, there is a clear need for improved transparency and evaluation within the GP's training in different Regions through a periodic monitoring system with specific indicators (quantitative and qualitative). The re-establishment/establishment of an independent national observatory on Training in General Practice would be desirable.

General practitioners' perceptions of using virtual primary care during the COVID-19 pandemic: An international cross-sectional survey study.

With the onset of COVID-19, general practitioners (GPs) and patients worldwide swiftly transitioned from face-to-face to digital remote consultations. There is a need to evaluate how this global shift has impacted patient care, healthcare providers, patient and carer experience, and health systems. We explored GPs' perspectives on the main benefits and challenges of using digital virtual care. GPs across 20 countries completed an online questionnaire between June-September 2020. GPs' perceptions of main barriers and challenges were explored using free-text questions. Thematic analysis was used to analyse the data. A total of 1,605 respondents participated in our survey. The benefits identified included reducing COVID-19 transmission risks, guaranteeing access and continuity of care, improved efficiency, faster access to care, improved convenience and communication with patients, greater work flexibility for providers, and hastening the digital transformation of primary care and accompanying legal frameworks. Main challenges included patients' preference for face-to-face consultations, digital exclusion, lack of physical examinations, clinical uncertainty, delays in diagnosis and treatment, overuse and misuse of digital virtual care, and unsuitability for certain types of consultations. Other challenges include the lack of formal guidance, higher workloads, remuneration issues, organisational culture, technical difficulties, implementation and financial issues, and regulatory weaknesses. At the frontline of care delivery, GPs can provide important insights on what worked well, why, and how during the pandemic. Lessons learned can be used to inform the adoption of improved virtual care solutions and support the long-term development of platforms that are more technologically robust and secure.

Evaluating the Impact of COVID-19 on the Adoption of Virtual Care in General Practice in 20 Countries (inSIGHT): Protocol and Rationale Study.

BACKGROUND: In recent decades, virtual care has emerged as a promising option to support primary care delivery. However, despite the potential, adoption rates remained low. With the outbreak of COVID-19, it has suddenly been pushed to the forefront of care delivery. As we progress into the second year of the COVID-19 pandemic, there is a need and opportunity to review the impact remote care had in primary care settings and reassess its potential future role. OBJECTIVE: This study aims to explore the perspectives of general practitioners (GPs) and family doctors on the (1) use of virtual care during the COVID-19 pandemic, (2) perceived impact on quality and safety of care, and (3) essential factors for high-quality and sustainable use of virtual care in the future. METHODS: This study used an online cross-sectional questionnaire completed by GPs distributed across 20 countries. The survey was hosted in Qualtrics and distributed using email, social media, and the researchers' personal contact networks. GPs were eligible for the survey if they were working mainly in primary care during the period of the COVID-19 pandemic. Descriptive statistical analysis will be performed for quantitative variables, and relationships between the use of virtual care and perceptions on impact on quality and safety of care and participants' characteristics may be explored. Qualitative data (free-text responses) will be analyzed using framework analysis. RESULTS: Data collection took place from June 2020 to September 2020. As of this manuscript's submission, a total of 1605 GP respondents participated in the questionnaire. Further data analysis is currently ongoing. CONCLUSIONS: The study will provide a comprehensive overview of the availability of virtual care technologies, perceived impact on quality and safety of care, and essential factors for high-quality future use. In addition, a description of the underlying factors that influence this adoption and perceptions, in both individual GP and family doctor characteristics and the context in which they work, will be provided. While the COVID-19 pandemic may prove the first great stress test of the capabilities, capacity, and robustness of digital systems currently in use, remote care will likely remain an increasingly common approach in the future. There is an imperative to identify the main lessons from this unexpected transformation and use them to inform policy decisions and health service design. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/30099.

On the importance of primary and community healthcare in relation to global health and environmental threats: lessons from the COVID-19 crisis.

In the course of the COVID-19 pandemic, it has become clear that primary healthcare systems play a critical role in clinical care, such as patient screening, triage, physical and psychological support and also in promoting good community advice and awareness in coordination with secondary healthcare and preventive care. Because of the role of social and environmental factors in COVID-19 transmission and burden of disease, it is essential to ensure that there is adequate coordination of population-based health services and public health interventions. The COVID-19 pandemic has shown the primary and community healthcare (P&CHC) system's weaknesses worldwide. In many instances, P&CHC played only a minor role, the emphasis being on hospital and intensive care beds. This was compounded by political failures, in supporting local community resilience. Placing community building, social cohesion and resilience at the forefront of dealing with the COVID-19 crisis can help align solutions that provide a vision of 'planetary health'. This can be achieved by involving local well-being and participation in the face of any pervasive health and environmental crisis, including other epidemics and large-scale ecological crises. This paper proposes that P&CHC should take on two critical roles: first, to support local problem-solving efforts and to serve as a partner in innovative approaches to safeguarding community well-being; and second, to understand the local environment and health risks in the context of the global health perspective. We see this as an opportunity of immediate value and broad consequence beyond the control of the COVID-19 pandemic.

General Practitioners' Experiences During the First Phase of the COVID-19 Pandemic in Italy: A Critical Incident Technique Study.

Since February 2020, when coronavirus disease began to spread in Italy, general practitioners (GPs) were called to manage a growing number of health situations. The challenges experienced by Italian GPs remained unrevealed. This study aimed at exploring Italian GPs' care experiences and practices associated with critical incidents during the first wave of the pandemic. A qualitative study design involving the critical incident technique through an online survey was applied. Sociodemographic data and open-ended responses were collected. While participants' characteristics were analyzed through descriptive statistics, qualitative data were thematically analyzed employing the framework method. 149 GPs responded to the survey and 99 participants completed the survey (dropout rate = 33%). Eight themes emerged indicating factors related to the organization of the healthcare system and factors related to the clinical management of patients, that were perceived as impacting on the GPs' care provision. The analysis revealed difficulties in communicating with other local services. This, together with the lack of coordination among services, was reported as a major challenge. Primary care was perceived as having been undervalued and criticalities in the organization of GP courses, led in a bureaucratic fashion, posed at risk some trainees to be infected. The digital technologies adopted for remote patient consultations were seen as useful tools for daily practice helping the GPs to stay emotionally connected with their patients. Besides, the improvement in the GP-patient relationship in terms of solidarity between patients and doctors and compliance to rules, had a positive impact. Moreover, many respondents addressed the importance of professional collaboration and teamwork, in terms of both support in practical issues (to find PPE, diagnostics and guidelines) and emotional support. At the same time, the lack of resources (e.g., PPE, swabs) and of specific guidelines and protocols impacted on the care provision. Our findings suggest that GPs in Italy are at risk of being left behind within the epidemic management. Communication and coordination among services are essential and should be substantially improved, and primary care research should be initiated to collect the context-specific evidence necessary to enhance the system's preparedness to public health emergencies and the quality of primary care services.

An itchy erythematous papular skin rash as a possible early sign of COVID-19: a case report.

BACKGROUND: Several recent studies suggest the possibility of a skin rash being a clinical presentation of coronavirus disease 2019 (COVID-19). The purpose of this case report is to bring attention to skin manifestations in the early stage of COVID-19 in order to support frontline physicians in their crucial activity of case identification. CASE PRESENTATION: The patient is an Italian 32-year-old female nurse who had several close contacts with multiple patients with COVID-19 as part of her professional workload. On March 13, 2020, the patient developed an itchy, erythematous papular rash (sparing only her face, scalp, and abdomen), which lasted for 10 days. The rash was accompanied by a feeling of general fatigue that gradually worsened over the following days and has continued for 5 months (until the end of July 2020). During the first week of remote assessment carried out by her general practitioner, the patient gradually developed a dry cough, intermittent fever, and diarrhoea and then had a positive test result for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Her skin manifestations disappeared completely 48 days after the onset of the disease, followed by the disappearance of the dry cough. CONCLUSIONS: In light of recent studies, this case report suggests that skin manifestations, when taken into account with other situational factors (such as profession and patient history) should be taken into proper consideration by frontline physicians as possibly being caused by SARS-CoV-2. Early identification of COVID-19 is a key part of the strategy of case detection and case isolation. To enhance this activity, further research is needed to establish frequency, symptoms, signs, and pathogenesis of skin manifestations in patients with COVID-19.

Broad Spectrum project: factors determining the quality of antibiotic use in primary care: an observational study protocol from Italy.

INTRODUCTION: The overuse of antibiotics is causing worldwide spread of antimicrobial resistance (AMR). Compared with other countries, Italy has both high antibiotic consumption rates and high rates of AMR. Due to the fact that around 90% of antibiotics are prescribed by general practitioners (GPs), this study aims to measure the impact of knowledge, attitudes and sociodemographic and workplace-related factors on the quality of antibiotic prescriptions filled by GPs in the Italian Region of Sardinia. METHODS AND ANALYSIS: Knowledge, attitude, sociodemographic and workplace-related factors deemed to influence physicians prescribing behaviour will be evaluated in a cross-sectional study conducted among all GPs of the Italian Region of Sardinia (n=1200). A knowledge and attitudes questionnaire (Knowledge and Attitudes on Antibiotics and Resistance - Italian version: ITA-KAAR) accompanied by a sociodemographic form will be linked to drug prescription data reimbursed by the National Health System. European Surveillance of Antibiotic Consumption quality indicators for outpatient antibiotic use will be calculated from drug prescription records. Every GP will be deemed to have demonstrated an adequate quality of prescriptions of antibiotics if half of the indicator score plus one is better than the median of the region. A multivariate Poisson regression model with robust variance estimation will be used to evaluate the impact of the determinants of antibiotic prescriptions on the actual prescribing quality of each physician. ETHICS AND DISSEMINATION: The project has been approved by the ethics committee of the Regional Health Trust of Sardinia (176/2019/CE, 24 September 2019). The results will be useful to inform evidence-based interventions to tackle irrational antibiotic use in the community.

[General practitioners knowledge and attitudes on antibiotics and resistance: cross-cultural adaptation and preliminary validation of KAAR-11 questionnaire.] / Conoscenze e attitudini dei medici di medicina generale riguardo all'antibiotico-resistenza e la prescrizione di antibiotici: adattamento cross-culturale e validazione preliminare del questionario KAAR-11.

Inappropriate prescriptions and consumption of antibiotics are the main determinants of the selection of antibiotic resistant bacteria. Italy has a high consumption rate of antibiotics if compared to other European countries and 90% of these drugs are prescribed in an outpatient setting by General Practitioners (GPs). Therefore, as stated by the Italian Medicines Agency (AIFA): «General Practice is [...] a crucial clinical area in which the utilization of these kind of drugs have to be monitored, [...] considering that a relevant quote of prescriptions could be avoided. Achieving a better understanding of the clinical and extra-clinical determinants of GPs prescription habits is, therefore, hugely important to design appropriate interventions to tackle the phenomenon of inappropriate antibiotic use. To the best of our knowledge, there are no published studies measuring GPs knowledge and attitudes on antibiotic resistance and prescriptions in our setting. To fill this lack of knowledge, the aim of our study is the development of a valid and reliable questionnaire in Italian language, able to measure these constructs. In this article, we present the process of cross-cultural adaptation of the KAAR-11 questionnaire from Spanish into Italian language and its preliminary validation.