Cutaneous melanoma diagnosis delay: socioeconomic and demographic factors influence

SUMMARY OBJECTIVE: Malignant cutaneous melanoma is the most aggressive type of skin cancer, and its early detection and prompt initiation of treatment play an important role in reducing disease-associated morbidity and mortality. Many factors influence the diagnosis of melanoma, and its recognition is essential for the development of strategies for its early detection. This study was carried out to Identify the main variables related to the delay in diagnosis of Malignant Cutaneous Melanoma and correlate them with the time interval for making the definitive diagnosis. METHODS: Retrospective analysis of 103 patient records from January 2015 to December 2020 correlating social, economic, demographic, and cultural factors with the time elapsed between the onset of symptoms and the diagnosis of malignant cutaneous melanoma. RESULTS: The average time to seek medical services from the onset of symptoms was 29.54 months. The mean time for a referral from the primary to the referral service was 1.35 months, and the factors that contributed to a faster diagnosis were lesion Breslow (>1 mm), lesion growth, income range (≤1.5 minimum wages), lower phototypes (I and II), not having gone to the Basic Healthcare Units, profession (household), smoking, and type of housing. CONCLUSIONS: Our findings demonstrate that there is still a great delay in the recognition of signs and symptoms related to the diagnosis of malignant cutaneous melanoma in our country, influenced by several socioeconomic and demographic factors.

Asian perspectives on NAPCRG.

This is a short communication to reflect on experiences at North American Primary Care Research Group (NAPCRG) conference from the perspective of Asian family physicians. They feel that NAPCRG can play an important role to level up the skills and talents in countries with less-established primary care research capacity and capability. NAPCRG should not be restricted to networking functions for only North America, Europe and Oceania but should include Asia, South America and Africa. These international academic networks will strengthen primary care research in the world.

Expectativas de inserción laboral en graduados de residencias de Medicina Familiar y General, Buenos Aires / Employment expectations of graduates from family and general medicine residencies, Buenos Aires

La Medicina Familiar y General (MFyG) es una especialidad clave en la estrategia de Atención Primaria de la Salud (APS). Sin embargo, en Latinoamérica se observa una disminución en la cantidad de aspirantes a las residencias de dicha especialidad y con los años abandono de su práctica. Explorar de manera prospectiva las expectativas de inserción laboral de los residentes del último año de MFyG y de los recientemente graduados e identificar el grado de incumbencia en el ámbito de la APS de las primeras experiencias laborales. Se realizó un estudio cualitativo y descriptivo, a través de 20 entrevistas semi-estructuradas y dos grupos focales a médicos de instituciones de gestión privada de la Ciudad Autónoma de Buenos Aires, durante el año 2019. Del análisis del corpus empírico surgieron 4 dimensiones: el perfil del médico de familia/general, la lucha por el reconocimiento de la especialidad, los factores que influyen en las primeras elecciones laborales y las expectativas laborales post residencia. Observamos que los médicos de familia/general se encuentran muy optimistas en la etapa de recién recibidos, con deseos de trabajar en el ámbito de la APS. Sin embargo, se ven obligados a enfrentar un mercado laboral que no aprecia (y hasta no comprende) su preparación. Las expectativas laborales se ven afectadas por una tensión entre ideas profundas sobre "lo correcto" de su trabajo y las oportunidades laborales reales en un sistema de salud que prioriza las especialidades de la fragmentación (AU)

Family and General Medicine is a key specialty in the Primary Health Care (PHC) strategy. However, in Latin America there has been a decrease in the number of physicians who choose and then practice it. To explore the Family and General Medicine residents' expectations on their labor transition after the last training year and identify the degree of concern in the field of PHC of the first work experiences. Qualitative study, through 20 semi-structured interviews and 2 focus groups involving Family and General physicians from privately managed institutions in Ciudad Autónoma de Buenos Aires, in 2019. From the analysis of the empirical corpus, four dimensions emerged: the profile of the family physicians, the fight for the recognition of the specialty, the factors that influence their first work experiences and the post-residency careers expectations. The graduates from Family and General Medicine residency programs interviewed have to face a difficult labour market that does not appreciate their training and does not understand what family physicians provide in terms of comprehensive care to patients. Therefore, tension arises between what is right and acceptable in their profession and the real job opportunities offered by the health system that prioritizes fragmented specialties (AU)

Diabetes mellitus y su influencia en la sexualidad de pacientes varones / Diabetes mellitus and its influence on the sexuality of male patients

RESUMEN Objetivo Estudiar cómo la diabetes mellitus tipo 2 ha influenciado la sexualidad de 54 varones mellitus que acudieron a consulta a dos hospitales de Taxco, Guerrero. Materiales y Métodos Se aplicó una encuesta a un total de 54 hombres que acudieron a consulta a dos hospitales de Taxco, Guerrero, México. Se consideró a hombres con diabetes mellitus tipo 2, con vida sexual activa, con más de 5 años de evolución de la enfermedad, y que acudieron a consulta periódica. Los casos se eligieron tomando en cuenta los planteamientos sobre muestras por conveniencia. El trabajo fue cuantitativo no probabilístico. El cuestionario de encuesta incluyó 15 variables. Resultados Entre los hallazgos alentadores y positivos se destaca que el 76% de los casos manifestó que nunca ha tenido una disminución en el desempeño sexual, y el 80% de los casos expresó nunca haber presentado dolor o molestia después del coito. Sobre los porcentajes adversos y negativos, el 33% manifestó haber tenido siempre un cambió (de manera nociva o dañina) en el interés ante la sexualidad. Conclusiones Diversos autores destacan cómo la diabetes mellitus es una enfermedad epidémica en México, y que provoca incapacidad, mortalidad prematura, y afecta de manera grave la sexualidad de pacientes. En el presente estudio las respuestas indican, tanto hallazgos positivos, como también, un impacto adverso y negativo en la sexualidad de algunos varones encuestados.

ABSTRACT Objective To study and analyze how type 2 diabetes mellitus has influenced the sexuality of male patients. Material and Methods A survey was applied to a total of 54 men who attended in two hospitals in Taxco, Guerrero, México. Men with type 2 diabetes mellitus, with an active sexual life, with more than 5 years of evolution of the disease, and who attended periodic consultations were considered. The cases were chosen taking into account the approaches on convenience samples. The work was quantitative, not probabilistic. The survey questionnaire included 15 variables. Results Among the findings encouraging and positive, it is highlighted that 76% of the cases reported never having had a decrease in sexual performance. Likewise, and 80% of the cases expressed never having presented pain or discomfort after inter-course. Regarding the adverse and negative percentages, the 33% stated that they had always had a change (in a harmful way) in their interest in sexuality. Conclusions Several authors highlight how diabetes mellitus is an epidemic disease in Mexico, which can cause disability and premature mortality, and seriously affect the sexuality of patients. In the present study the responses indicate both positive findings, as well as an adverse and negative impact on the sexuality of some male respondents.

Percepção de egressos de um curso de Odontologia no sul do Brasil sobre a inserção no mercado de trabalho / Perception of entry into in the labor market among dental graduates from a university in southern Brazil

O objetivo do presente estudo foi conhecer a percepção de egressos de um Curso deOdontologiano sul do Brasilsobre a inserção no mercado de trabalho. Para isso, foi aplicado um questionário online, por meio da Plataforma Google Forms, com onzequestões abertas e fechadas aos cirurgiões-dentistasformadosna instituição nos últimos dois anos.O questionário foi estruturado a fim de analisar como está sendo realizada a inserção e a prática profissional dos recém-formados no mercado de trabalho.Os dados coletados foram transferidos para uma planilha e analisados por meio defrequênciasabsoluta e relativanas questões fechadas e descritiva nas questões abertas. Amaioria dos respondentes apontaram estar capacitados para o mercado de trabalho tanto sob ponto de vista técnico,com familiaridade em relação aosmateriais e equipamentos disponíveis,quanto sob o ponto de vista de pessoal. As disciplinas de clínica integrada, os Centros de Especialidades Odontológicasdo Sistema Único de Saúde, extensões e estágios extramuros foramelencados por promoverem uma vivência do trabalho em equipe e da integralidade das diversas especialidades da odontologia (AU).

This study examined the perception of entry into the labor market of graduates from a School of Dentistry in southern Brazil. An online questionnaire with eleven open and closed questions was created using Google Forms and applied to recently graduated dentists in an educational institution in southern Brazil. The questionnaire asked questions about the entry into the labor market and the professional practice of recent graduates. The data collected in the questionnaires were transferred to an Excel® spreadsheet and analyzed using absolute and relative frequency for closed questions and descriptive statistics for open questions. Most respondents felt that they were technically qualified for the labor market, considering familiarity with the materials and equipment available, and personally well prepared. Integrated clinics, Dental Specialties Centers of the Brazilian Unified Health System (SUS), extension courses and internships were listed as factors that promoted teamwork and integrated experiences in the various dental specialties (AU).

Resgatando a importância dos relatos de caso na Medicina / Recovering the importance of case reports in Medicine

Objetivos: Resgatar a importância dos estudos de caso na história da Medicina através de relatos consagrados que mudaram os panoramas da Saúde. Conteúdo: Os relatos de caso são estudos observacionais descritivos que tem como finalidade contar um acontecimento raro ou novo por meio de sua história clínica baseada em sintomatologia, métodos diagnósticos e terapêuticos existentes, seguida de uma discussão sobre o assunto abordado. Sua origem vem do Egito Antigo, sendo estabelecido mundialmente por meio de Hipócrates, considerado o "pai da medicina". Embora tenha mudado o rumo da Medicina, atualmente esse tipo de estudo vem sofrendo críticas da comunidade científica que questiona sua metodologia, simplicidade e a falta de uso para pesquisas futuras. Porém, os relatos de caso foram, são e serão importantes para a área médica, pois contribuem para o descobrimento de novas doenças, mecanismos fisiopatológicos, tratamentos, efeitos colaterais e medidas profiláticas. Conclusões: Apesar das atuais críticas, os relatos de caso devem ser valorizados por sua importância histórica na Medicina e é necessário resgatar sua essência para não caírem no esquecimento

Objectives: Rescue the importance of case studies in the history of Medicine through renowned stories that have changed the panoramas of Heathcare. Contents: Case reports are descriptive observational studies that aim to tell a rare or new event through its clinical history based on symptoms, existing diagnostic and therapeutic methods, followed by a discussion on the subject address. Its origin comes from Ancient Egypt, being established worldwide though Hipócrates, considered the "father of medicine". Although it has changed the course of medicine, currently this type of study has suffered criticism from the scientific community that questions its methodology, simplicity and the lack of use for future research. However, case reports were, are and will remain important to the medical field, as they contribuite to the discovery of new diseases, pathophysiological mechanisms, treatments, side effects and prophylactic measures. Conclusions: Despite the current criticism, case reports should be valued for their historical importance in medicine and it is necessary to rescue their essence so that they do not fall into oblivion.

Diagnósticos frecuentes de consulta externa de medicina general de la Universidad Santo Tomás (USTA), Bucaramanga, 2015-2017 / Frequent diagnosis in primary care physician services of the Santo Tomás University (USTA), Bucaramanga, 2015-2017

RESUMEN Objetivo Determinar los diagnósticos más frecuentes de los pacientes atendidos en el servicio de consulta externa de medicina general de la Universidad Santo Tomás (USTA), seccional Bucaramanga, entre 2015 y 2017. Método Estudio descriptivo retrospectivo de los registros diarios de pacientes atendidos en el servicio médico con un N=13 892 pacientes -estudiantes, administrativos, docentes, egresados y División de Educación Abierta y a Distancia (DUAD)-. Se excluyeron 5 907 registros para un n=7 985 datos de exploración, correspondientes a pacientes que hicieron uso exclusivamente del servicio de consulta médica. Resultados 5 808 (73%) de las consultas fueron realizadas por mujeres y 2 177 (27%) hombres; jóvenes entre 19 y 26 años (60,9%), estudiantes de pregrado (71,8%), de odontología (29,6%) y derecho (26,5%), atendidos por enfermedades del aparato respiratorio (16,4%), con afectaciones más frecuentes a adolescentes (15,4%) y jóvenes (17,2%). La rinofaringitis aguda fue el principal diagnóstico CIE-10. Los jóvenes consultaron por diarrea y gastroenteritis de presunto origen infeccioso (6,7%); los adultos (5,7%) y docentes (6,1%), por cervicalgia, y el personal administrativo, por infección viral no especificada (5,7%). Conclusiones La población atendida en consulta médica de la USTA entre 2015 y 2017 fueron principalmente mujeres y jóvenes entre 19 a 26 años. Las enfermedades transmisibles como las enfermedades del aparato respiratorio fueron más frecuentes que las enfermedades crónicas no transmisibles, principalmente la rinofaringitis aguda, enfermedad de alta transmisibilidad en comunidad. Las mujeres, adolescentes y estudiantes de pregrado, fueron atendidos en consulta por consejo y asesoramiento sobre la anticoncepción, lo que coincide con la Encuesta Nacional De Demografía y Salud.

ABSTRACT Objective To determine the most frequent diagnoses of the patients treated in primary medical care services of the Santo Tomás University (USTA, by its initials in Spanish), Bucaramanga section, between 2015 and 2017. Method A retrospective descriptive study of the daily records of patients treated in primary medical care services with an N=13 892 patients -students, administrative workers, professors, graduates, and Open and at Distance Education Division (DUAD, by its initials in Spanish)-. 5 907 records were excluded for a n=7 985 scan data corresponding to patients who used the medical consultation service exclusively. Results 5 808 (73%) of the consultations were conducted by women and 2 177 (27%) by men; young people between 19 and 26 years (60.9%), undergraduate students (71.8%), in dentistry (29.6%) and law (26.5%), people treated for respiratory diseases (16.4%), affected adolescents (15.4%) and young people (17.2%) more frequently. Acute rhinopharyngitis was the main diagnosis ICD-10. Young people consulted for diarrhea and gastroenteritis of suspected infectious origin (6.7%); adults (5.7%) and professors (6.1%), for neck pain, and administrative workers, for unspecified viral infection (5.7%). Conclusions The population who attended medical consultation of the Santo Tomás University in Bucaramanga throughout 2015-2017 were mainly women and young people between 19 and 26 years. Communicable diseases such as respiratory diseases were more frequent than chronic noncommunicable diseases, mainly acute rhinopharyngitis, a disease of high transmissibility in the community. Women, adolescents, and undergraduate students were treated in consultation for contraceptive counseling, which coincides with the National Demography and Health Survey.

COVID-19 in dental practice ­ an overview of challenges and preventive measures / COVID-19 na prática odontológica ­ uma revisão sobre os desafios e medidas preventivas

COVID-19 was identified to be caused by a new coronavirus named as SARS-CoV-2. Since the outbreak of this disease, World Health Organization (WHO) declared a global public health emergency. SARS-CoV-2 has a high estimate rate of human-tohuman transmission mainly through inhalation/ingestion/direct mucous contact with respiratory droplets. Considering this high transmission capacity, several countries have already registered cases of infection by health professionals. Even though dentists are not directly involved in the diagnosis and therapy of COVID-19 they represent undoubtedly a risk group due to high exposure and their work environment is a contagion factor for patients and staff. In this manner, the objective of this article is to approach important aspects of COVID-19 concerning dental care and provides an overview of its challenges on dental practice. For this, we used these following keywords in our research: COVID-19; dental general practice; prevention and control; infectious disease transmission; infectious disease transmission, patient to professional. Taking into account the global concern with patient care in midst of this pandemic, we address valid concerns regarding the potential means of contamination in the dental office and highlight practices and guidelines adopted in different countries to minimize risks in dental care in this global public health crisis, thus, reinforcing the challenges of dentistry in this context, highlighting the importance of rigorous preventive measures. However, there is still a lack of standardization of dental care protocols and consequently, reduce the risk of contagion.

COVID-19 foi identificada como sendo causada por um novo coronavírus denominado SARS-CoV-2. Desde o surgimento da doença, a Organização Mundial da Saúde (OMS) declarou uma emergência global de saúde pública. O SARS-CoV-2 tem uma alta taxa estimada de transmissão de pessoa para pessoa, principalmente por inalação/ingestão/contato direto da mucosa com gotículas respiratórias. Considerando essa alta capacidade de transmissão, vários países já registraram casos de infecção por profissionais de saúde. Mesmo que os dentistas não estejam diretamente envolvidos no diagnóstico e terapia do COVID-19, eles representam, sem dúvida, um grupo de risco devido à alta exposição e seu ambiente de trabalho é um fator de contágio para pacientes e equipe. Dessa forma, o objetivo deste artigo é abordar aspectos importantes do COVID-19 no que diz respeito à assistência odontológica e apresentar um panorama de seus desafios na prática odontológica. Para isso, utilizamos as seguintes palavras-chave em nossa pesquisa: COVID-19; clínica odontológica geral; prevenção e controle; transmissão de doenças infecciosas; transmissão de doenças infecciosas do paciente para o profissional. Levando em consideração a preocupação global com o atendimento ao paciente em meio a esta pandemia, foram abordadas preocupações válidas sobre os meios potenciais de contaminação no consultório odontológico e destacadas as práticas e diretrizes adotadas em diferentes países para minimizar os riscos na assistência odontológica nesta crise global de saúde pública, reforçando assim os desafios da odontologia neste contexto, evidenciando a importância de medidas preventivas rigorosas. Porém, ainda falta padronização dos protocolos de atendimento odontológico e, consequentemente, redução do risco de contágio.

Pregnancy during the course of Cushing's syndrome: a case report and literature review.

SUMMARY: Cushing's syndrome is an endocrine disorder that causes anovulatory infertility secondary to hypercortisolism; therefore, pregnancy rarely occurs during its course. We present the case of a 24-year-old, 16-week pregnant female with a 10-month history of unintentional weight gain, dorsal gibbus, nonpruritic comedones, hirsutism and hair loss. Initial biochemical, hormonal and ultrasound investigations revealed hypokalemia, increased nocturnal cortisolemia and a right adrenal mass. The patient had persistent high blood pressure, hyperglycemia and hypercortisolemia. She was initially treated with antihypertensive medications and insulin therapy. Endogenous Cushing's syndrome was confirmed by an abdominal MRI that demonstrated a right adrenal adenoma. The patient underwent right laparoscopic adrenalectomy and anatomopathological examination revealed an adrenal adenoma with areas of oncocytic changes. Finally, antihypertensive medication was progressively reduced and glycemic control and hypokalemia reversal were achieved. Long-term therapy consisted of low-dose daily prednisone. During follow-up, despite favorable outcomes regarding the patient's Cushing's syndrome, stillbirth was confirmed at 28 weeks of pregnancy. We discuss the importance of early diagnosis and treatment of Cushing's syndrome to prevent severe maternal and fetal complications. LEARNING POINTS: Pregnancy can occur, though rarely, during the course of Cushing's syndrome. Pregnancy is a transient physiological state of hypercortisolism and it must be differentiated from Cushing's syndrome based on clinical manifestations and laboratory tests. The diagnosis of Cushing's syndrome during pregnancy may be challenging, particularly in the second and third trimesters because of the changes in the maternal hypothalamic-pituitary-adrenal axis. Pregnancy during the course of Cushing's syndrome is associated with severe maternal and fetal complications; therefore, its early diagnosis and treatment is critical.

Anaphylaxis and other allergic reactions to food: a global challenge.

We describe a case of a biphasic anaphylactic reaction that occurred in a young woman soon after the ingestion of soy milk that led to her hospitalisation. Early recognition and appropriate treatment led to a successful outcome of this life-threatening condition. Challenges encountered in the care of this common illness are highlighted. There is a need for an increase in public awareness on dangerous allergic reactions caused by allergens present in food products in public use, thereby facilitating primary preventative measures to minimise its occurrence. Healthcare stakeholders need to implement measures of contemporary preventative medicine and efficient therapeutic protocols to safeguard the public welfare concerning this global health problem where appropriate interventions can reduce morbidity and mortality. Trial registration numbers NCT02991885 and NCT02851277.

Office-based approach to urinary tract infections in 50 000 patients: results from the REWIND study.

OBJECTIVES: The REWIND study sought to describe the real-world clinical and prescribing practices for the management of urinary tract infection (UTI) in Italy, Belgium, Russia and Brazil in order to compare current practices with international, European and national guidelines. METHODS: An integrated mixed-methods approach was adopted that used information from primary care electronic medical records in longitudinal patient databases available in Italy and Belgium, and surveys of physicians in Russia (general practitioners) and Brazil (gynaecologists). RESULTS: In total, 49 548 female patients were included in the study. Antibiotics were the most common management option for UTI in Italy (71.1%, n=27 600), Belgium (92.4%, n=7703), Russia (81.9%, n=1231) and Brazil (82.4%, n=740). Fosfomycin trometamol was the first-choice antibiotic for the treatment of UTI in all countries. Ciprofloxacin was also commonly prescribed in Italy (24.6%, n=6796), Belgium (17.8%, n=1373), Russia (14.9%, n=184) and Brazil (9.6%, n=71), while prescription of nitrofurantoin was common in Belgium (24.5%, n=1890) alone. CONCLUSIONS: Despite differences in study designs and data sources, fosfomycin trometamol was found to be the most commonly prescribed treatment for UTI in all participating countries. In Belgium, real-world prescribing practices for UTI adhered more closely to European guidelines than national guidelines. Although not recommended in international and European guidelines for lower UTI management, the use of fluoroquinolones was still widespread.

Classificação Internacional de Atenção Primária: capturando e ordenando a informação clínica / The International Classification of Primary Care: capturing and sorting clinical information

Resumo A Classificação Internacional de Atenção Primária-2 (CIAP-2) é fruto de quarenta anos de desenvolvimento contínuo. Tem origem na segunda metade do século XX, a partir da inquietação de médicos gerais com a necessidade de se registrar e codificar dados especificamente relacionados à atenção primária, tanto nos motivos de consulta quanto nos procedimentos e nas condições ou diagnósticos. A Organização Mundial de Saúde chancelou a classificação bem como o seu comitê desenvolvedor após o encontro de Alma-Ata, pois também identificou necessidades específicas. Hoje há essencialmente duas formas de uso na coleta de informações: por encontro ou por episódio de cuidado. A segunda forma é mais complexa e controversa. Recentemente foi lançada a décima primeira versão da Classificação Internacional de Doenças, enquanto que a CIAP-3 esta sendo desenvolvida. Não há como prever como vão interagir com as novas tecnologias, as classificações e os organismos internacionais. O protagonismo dos profissionais da ponta e dos pacientes tem potencial de definir a direção.

Abstract The International Classification of Primary Care-2 (ICPC-2) is the result of forty years of continuous development. It originates in the second half of the twentieth century after the concern of general practitioners about the need to record and encode data specifically related to primary care, both in the reasons for encounter and procedures and conditions or diagnoses. The World Health Organization endorsed the classification, as did the developer committee after the Alma Ata meeting, since it also identified specific needs. Two forms of use are employed now in gathering information: by encounter or by an episode of care. The latter is more complex and controversial. Recently, an eleventh version of the International Classification of Diseases has been released, and the third edition of ICPC is being developed. One cannot predict how new technologies, classifications, and international organizations will interact. The role of front line health professionals and patients will define the course.

Atypical presentation of acute rheumatic fever (ARF) in a 25-year-old woman in the Caribbean: a challenging diagnosis.

A 25-year-old woman presented a challenging diagnosis of acute rheumatic fever (ARF). Initial symptoms included dry cough and three minor Jones criteria (unabating fever (38.4°C, 0d), elevated acute phase reactants (C-reactive protein, 13d) and joint pain (monoarthralgia) in her neck (0d)). ARF was diagnosed only after presentation of two major Jones criteria (polyarthritis/polyarthralgia (16d) and erythema marginatum (41d)) and positive antistreptolysin O titre (44d). Parotid swelling, peripheral oedema, elevated liver enzymes and diffuse lymphadenopathy complicated the diagnosis. Throat swab, chorea and carditis were negative or absent. Atypical ARF is challenging to recognise. There is no diagnostic test and its presentation is similar to that of other diseases. While the 2015 Jones criteria modification increased specificity of ARF diagnosis, atypical cases may still be missed, especially by physicians in developed countries. Suspicion of atypical ARF, especially after travel to high incidence regions, would allow for earlier treatment and prevention of rheumatic heart disease.

Advanced Practice Nursing in Primary Health Care in the Spanish National Health System / Enfermagem Prática Avançada em atenção primária no Sistema Nacional de Saúde espanhol

Abstract The primary health care in the Spanish National Health System is organised in health centres with multi-professional teams, composed of doctors and nurses specialised in family and community health, in addition to other professionals. This article analyses the role of primary health care nurses in the Spanish National Health System. In the last decade, new concepts of task sharing between doctors and nurses as well as advanced nursing roles have been evolved in the health centres that focus on improving care for chronically ill patients and access to primary care. With shared responsibility, nurses are responsible for chronic patients in stable conditions, health prevention and promotion. The scaling up of advanced nursing tasks is limited by uncertainties of roles, disparities between states, and legislations that do not cover the full extent of advanced nursing tasks. The case study of Spain indicates that a strong multi-professional model of primary health care teams is a crucial basis for the evolvement of advanced nursing practice and its acceptance in daily routines. However, advantageous education structures and legislations are needed to allow nurses to develop their contribution in the full potential.

Resumo A atenção primária no Sistema Nacional de Saúde espanhol é prestada em centros de saúde públicos, com equipe composta de médicos e enfermeiros especialistas em família e comunidade, além de outros profissionais. Neste artigo, se analisa a atuação do enfermeiro na atenção primária no Serviço Nacional de Saúde espanhol. Na última década, buscando efetividade no manejo de condições crônicas e melhor acesso à atenção, novos modelos de ações compartilhadas entre médicos e enfermeiros, bem como práticas avançadas de enfermagem foram desenvolvidas. Atualmente, com responsabilidades compartilhadas, enfermeiros são responsáveis por pacientes com condições crônicas estáveis, além de ações de prevenção e promoção. Não obstante, a prática avançada em enfermagem é limitada por indefinição de funções, disparidade de atuação entre Estados e legislação insuficiente, que não abarca o potencial desta prática. O caso da Espanha indica que um modelo de atenção multiprofissional forte na atenção primária é crucial para o desenvolvimento da enfermagem de prática avançada. Entretanto, promover formação e legislação adequada à essa prática é necessário, para que os enfermeiros contribuam com todo o seu potencial na atenção primária à saúde.

Implementation of the Choosing Wisely Campaign at a Medical Clinic Internship / Implementação da Campanha Choosing Wisely no Internato de Clínica Médica

Abstract: Objective: to evaluate the implementation of the Choosing Wisely (CW) campaign strategies at a medical clinic internship. Methods: This interventional study involved internship teachers and students, using online questionnaires on the SurveyMonkey platform, and face-to-face activities. Using the Delphi technique, teachers identified three unnecessary situations that commonly occur in practice. The recommendations were grouped by frequency and subject, adapted to the CW format. A Likert scale was used to classify the specialists' opinion aiming to obtain the final list of recommendations. Before the introduction of the CW campaign, we conducted an Objective Structured Clinical Examination (OSCE). Two groups of students were compared: one group that underwent the same OSCE evaluation before the implementation of the CW campaign (110), and another group that participated of all educational actions (n = 98). The CW campaign was implemented by developing educational actions using the recommendations during workshops, banners, and theoretical evaluation, in addition to an Objective Structured Clinical Examination (OSCE). Results: after grouping the recommendations, 24 items remained. The specialists selected eight recommendations by frequency, addressing unnecessary behaviors such as requesting multiple exams, overuse of non-hormonal anti-inflammatory drugs, the indication of digestive endoscopy in younger patients with dyspepsia, excessive chest X-rays in intensive care unit, prescribing antibiotic prophylaxis for longer than recommended, routine indication of allergic tests, inadequate initial screening for thyroid assessment, and spirometry in asymptomatic patients. The educational actions resulted in a process of awareness and discussion among the participants, evidenced by theoretical evaluation (> 95%), as well as in the OSCE, where the level of successes was higher in the exposed group when compared to the nonexposed group (p = 0.001). Conclusion: the implementation of the CW campaign improved the clinical skills of medical clinic internship students and allowed positive discussions about cost-consciousness in health.

Resumo: Objetivo: avaliar a implementação de estratégias da campanha Choosing Wisely (CW) no internato de clínica médica. Métodos: Este estudo de intervenção envolveu professores e alunos do internato, por meio de questionários on-line na plataforma SurveyMonkey e atividades presenciais. Usando a técnica Delphi, os professores identificaram três situações desnecessárias que geralmente ocorrem na prática. As recomendações foram agrupadas por frequência e assunto e adaptadas ao formato CW. Utilizou-se uma escala Likert para classificar a opinião dos especialistas, obtendo-se a lista final de recomendações. Antes da introdução da campanha da CW, realizamos um Exame Clínico Objetivo Estruturado (OSCE). Foram comparados dois grupos de estudantes: um grupo que realizou a avaliação OSCE antes da implantação da campanha CW (110) e outro que participou de todas as ações educativas (n = 98). Implementamos a campanha da CW, desenvolvendo ações educativas usando as recomendações durante oficinas, banners e avaliação teórica, além de um Exame Clínico Objetivo Estruturado (OSCE). Resultados: após o agrupamento das recomendações, restaram 24 itens. Os especialistas selecionaram oito recomendações, abordando comportamentos desnecessários como solicitação de vários exames, uso excessivo de anti-inflamatórios não hormonais, indicação de endoscopia digestiva para pacientes mais jovens com dispepsia, excesso de radiografia de tórax em unidade de terapia intensiva, prescrição de profilaxia antibiótica por mais tempo do que o recomendado, indicação de rotina de testes alérgicos, triagem inicial inadequada para avaliação da tireóide e espirometria em pacientes assintomáticos. As ações educativas resultaram em conscientização e discussão entre os participantes, evidenciado por meio de avaliação teórica (> 95%), bem como no OSCE, onde o nível de sucessos foi maior no grupo exposto quando comparado ao grupo não exposto (p = 0,001). Conclusão: a implementação da campanha CW melhorou as habilidades clínicas dos estudantes do internato em clínica médica e permitiu discussões positivas sobre custo-consciência em saúde.

Training of general practitioners, a Mexican medical school curriculum evaluation / Formación de médicos generales, evaluación curricular en una escuela mexicana de medicina

Background: Educational curricula require constant improvement to respond to the needs of students, institutions and society. Objective: To evaluate the Plan de Estudios 2010 of the Facultad de Medicina de la Universidad Nacional Autónoma de México. Methods: Documentary and qualitative study of three phases. First, revision of trends of general medicine in special databases and comparison of curricula between universities. Second, focus groups with clinical teachers and basic sciences to investigate experiences and opinions in relation to trends in general medicine. Third, a "Generalists Committee" was convened to whom the results were presented (phase one and two) and the recommendations were adapted to adapt the results to the general practitioner's context. The participants were informed about the research objective and their participation was voluntary, the anonymity of theirs comments was protected. Results: The trend towards specialization in clinical practice defines the future of general medicine, and the administrative uses have an impact on the practices of the general practitioner and on the patient's medical relationship. Conclusion: Various aspects mainly educational and assistance hindered the quality of the practice of general medicine.

Introducción: los currículos educativos requieren estar en constante perfeccionamiento para responder a las necesidades de estudiantes, instituciones y de la sociedad. Objetivo: evaluar el Plan de Estudios 2010 de la carrera de medicina de la Facultad de Medicina de la Universidad Nacional Autónoma de México. Métodos: estudio documental y cualitativo, de tres fases. En la primera se revisaron las tendencias de la medicina general en bases de datos especializadas y se compararon los planes de estudios entre universidades. En la segunda, se realizaron grupos focales con docentes clínicos y de ciencias básicas para indagar experiencias y opiniones en relación con las tendencias de la medicina general. En la tercera, se convocó a un "Comité de Generalistas" a quienes se les presentaron los resultados de las fases anteriores, y se realizaron las recomendaciones pertinentes para adecuar los resultados al contexto del médico general. La participación de los entrevistados fue voluntaria, fueron informados sobre el objetivo de investigación y se resguardó el anonimato de sus testimonios. Resultados: la tendencia hacia la especialidad en la práctica clínica define el futuro de la medicina general; asimismo, los intereses administrativos repercuten en las prácticas del médico general y en la relación médico-paciente. Conclusión: diversos aspectos, principalmente educativos y asistenciales, obstaculizan la calidad de la práctica de la medicina general.

Chronic migraine headache and multiple dental pathologies causing cranial pain for 35 years: the neurodental nexus.

We report a case that illustrates how chronic migraine headaches and multiple dental pathologies caused severe and long-standing cranial pain that affected the quality of life of a man for more than 35 years. His case was investigated at several settings including the neurology outpatient clinic of the hospital without a definitive diagnosis or resolution. After investigations, multiple oral pathologies including two occult dental abscesses were diagnosed. Once both affected teeth and associated abscesses were surgically removed, with subsequent antibiotic therapy the headaches resolved.