Visions for the future, vocational training and special aspects esp. family violence

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Core Values of Family Medicine:

Threats and Opportunities

BOOK

OF ABSTRACTS

Organized by

DEGAM (WONCA Member)

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CONTENT

Abstracts are listed by topics. Please use the number of the page to navigate to requested topic. By using the the button CONTENT at each page, you can go back to main page. To search particular abstract or specific word, please use the pdf search button.

Keynote Lectures………...3

1. Managing primary care / Praxismanagement……….5

1.1. Diagnostic strategies / Diagnostische Strategien……….5

1.2. Call centers and e-health / Callcenter und digitale Lösungen……….127

1.3. Emergency medicine and health care utilization / Notfallmedizin und Nutzung des Gesundheitssystems………..141

1.4. Rural practice / Ländliche Praxis………177

1.5. Early diagnosis and risk assessment, risk perception / Früherkennung, Risikobewertung und-Wahrnehmung………185

2. Special groups of patients / Spezielle Patientengruppen………..282

2.1. Geriatric care / Geriatrie………..282

2.2. Palliative care / Palliative Versorgung……….314

2.3. Polypharmacy / Polypharmazie………332

2.4. Medical care to vulnerable groups (including social workers) / Versorgung vulnerabler Gruppen (ggf Einbeziehung Sozialarbeit)………..339

2.5. Chronic disease management / Management chronischer Krankheiten ………416

3. General aspects / Allgemeine Aspekte……….508

3.1. Ethical issues / Ethische Aspekte………508

3.2. Methodology in research / Forschungsmethodik………518

3.3. Health technology asessment in primary care / HTA-Berichte in der Primärversorgug……….535

3.4. Compassionate health care / Zuwendungsorientierte Versorgung ……….546

3.5. Big data………..570

3.6. Quality and safety / Qualität und Sicherheit………577

3.7. Precision medicine / Präzisionsmedizin………..628

4. Practice training / Aus-/Fort- und Weiterbildung………..645

4.1. Undergraduate and postgraduate practice training / Aus- und Weiterbildung………..645

4.2. Other Professional development (CPD, research training) / Fortbildung: medizinisch oder forschungsbezogen………..734

4.3. Case presentations and discussions by young doctors with slido- System / Fallpräsentationen und Diskussionen durch junge Ärzte/innen………..771

5. Future settings for primary care / Zukunftsaspekte……….783

5.1. FM´s/GP´s position in healthcare systems, intersectoral cooperation / Stellung des Hausarztes im System, intersektorale Kooperation………..783

5.2. Task shifting in primary care / Geänderte Aufgaben der Allgemeinmedizin………..803

5.3. Financial constraints, attractiveness of GP work / Finanzielle Einengung, Attraktivität der hausärztlichen Tätigkeit………809

5.4. Teamwork / Teamarbeit………...814

5.5. Preventive strategies, health promotion / Prävention, Gesundheitsförderung………824

5.6. Integrated/comprehensive primary care / Integrierte/umfassende Primärversorgug………857

5.7. Public health issues / Public health Aspekte………..873

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Keynote Lectures

Contribution ID: 1892

Patient centeredness and patient safety– how can GPs meet both these goals?

Amanda Howe

Primary Care, UEA, Norwich, Norfolk, United Kingdom

One of the major challenges in generalist practice is to be competent in many areas of clinical knowledge, procedural skills, and evidencebased options for testing and treating. Another is to link all of this ‘doctor’ agenda with the needs, views and unique situation of each person who is their patient. While it is a recurring pleasure of being a GP to enter again and again into the challenge of putting the person at the centre of our practice, we also have to manage our time, our own emotional and intellectual capacity, and offset the needs of the patient in front of us with the many who also need our help. And we know that overload, whether at an individual or systemic level, is a major cause of error and also professional burnout. The additional uncertainties and consequent safety measures which have been introduced by the COVID19 pandemic have added to our dilemmas – how to make safe diagnoses and be patient centred in the remote consultation setting, and how to retain the breadth of our best practice while meeting the added demands of the new context. This keynote will attempt to move beyond these dilemmas to share some lived experience and principles that can guide us to achieve both goals.

Conflict of interest / Interessenkonflikte no / nein

Visions for the future, vocational training and special aspects esp. family violence

Raquel Gomez Bravo

Institute for Health and Behaviour. Research Unit INSIDE, University of Luxembourg, Luxembourg, Luxembourg

Family violence is a global public health problem, which constitutes a violation of human rights and is considered a hidden epidemic. Family violence (also named domestic violence, domestic abuse or battering) includes intimate partner violence, child abuse/neglect and elder abuse, among others and can take many forms: physicial, emotional, verbal, sexual, physchological, etc. Its consequences involve serious damage to the physical, mental and social well-being of individuals and families.

Primary health care professionals may be the first or only point of contact for victims who may be hesitant or unable to seek other sources of assistance. These professionals are in the unique position to offer a safe and confidential environment to facilitate disclosure of violence, and provide appropriate support and referral to other resources and services.

Evidence shows that abused women use health care services more than non-abused women, and identify health care professionals as those who they would trust the most with disclosing an abuse. Yet, they tend not to disclose abuse unless specifically asked. Therein lies a problem: most of the practicing physicians have received either no or insufficient education or training in any aspect of family or gender violence.

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Why are we not prepared to face an epidemic like this? What are the reasons behind this lack of knowledge and barriers to take action? How can we, health care professionals in the frontline, assume our roles and responsibilities to provide the best care possible to victims, families and perpetrators?

Hospital at home, home care, palliative care

Ron Sabar

Home Hospital, Sabar Health, Even Yehuda, Israel

As the medical needs of people are expected to increase substantially in the immediate future, health care policymakers and providers must rethink the currant modal of providing health care. Two hundred years after the modern hospital revolution, started by pioneers such as Florence Nightingale, the pendulum of place of care, is slowly shifting from the hospitals and clinics, back to our patients homes. Just like the biggest taxi company in the world has no taxi cars of its own (Ubber) and the biggest hotel company in the world has no hotel rooms of its own (Airbnb), so will the largest hospitals in the world, in the vary near future, have no hospital beds of their own. Health care is going back home, or rather to the homes of our patients. It is true for end of life care as it is for acute care. As primary health care providers we must re-define our role in this revolution. This process involves both the macro elements of care coordination, but also the micro process of learning all over again the art of taking care of people in their own home without them having the feeling that we have 'invaded their castles'. We call it 'Being a Professional Guest'. Because even though, it's still about patients, health care providers and medicine-they are not the same patients they were 200 years ago, we are not the same health care providers and it is certainly not the same medicine.

Experience with Covid-19 pandemic

Maria van den Muijsenbergh1)_{, Andrea Canini}2)

1)_{Primary and Comunity care, Radboud University Medical Centre Nijmegen, Nijmegen, Netherlands} 2)_{Special Units of Primary Care, Italy}

Family Doctors are in the frontline of this pandemic, working under high pressure and the threat of becoming ill themselves. They are often the first to assess, diagnose and treat patients with Covid-19. In a short time they adjusted their practices to protect both their patients and themselves from the silent presence of Sars-Cov2. The pandemic has a severe impact on the population, and undoubtedly socially deprived groups are the most affected. Indeed, already existing inequalities are being exacerbated by the current situation. How do family doctors deal with these challenges? How are they managing to protect the most vulnerables? Together with such challenges, this time also presents us with opportunities. Effective approaches underpin the value of a strong Primary healthcare system, and of the core values of family medicine. In our lecture we will show evidence of the impact of Covid-19 on Family Practice and the importance of strong primary care collaboration, as well as a practical example on how to deliver person-centred integrated Primary Care to vulnerable groups.

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1. Managing primary care / Praxismanagement

1.1. Diagnostic strategies / Diagnostische Strategien

Abstract subtopic / Abstract Unterthema

1.1. Diagnostic strategies / Diagnostische Strategien

Presentation form / Präsentationsform

Workshop

Help-my patient has a sick liver! Hepatology-workshop for GPs

Monique Aubart-Schuller

Luxemburgish Sientific Society of General Practice, Luxembourg, Luxembourg

Abnormal liver tests are regularly seen in blood test results of asymptomatic patients. How should we interpret these results or react to them? Is it reasonable to search for common or rare diseases?

After a brief theoretical explanation, we will describe the diagnostic workup steps in general practice and give simple methods to handle these abnormal results. This workshop will treat different situations in general practice by means of clinical vignettes the participants are going to work on. It adresses to students, young and senior doctors who feel uncomfortable in hepatology.

ePoster

Paraneoplastic neuropathy associated with Hodgkin’s lymphoma

Snezana Knezevic1)_{, Marijana Jandric - Kocic}2)

1)_{Health care center, Kraljevo, Serbia}

2)_{Health care center, Krupa na Uni, R Srpska, Bosnia and Herzegovina}

Background: Paraneoplastic neuropathy occurs in patients with cancer and can not be explained by tumor,

metastasis, infections and adverse effects of cancer treatment.

Questions: How emerges paraneoplastic neuropathy in early stage cancer? Methods: Case report from practice.

Outcomes: A 38-year-old male patient presented with weight loss, night sweats weakness and sensory loss

in the lower extremities. He had symmetrical, ascending neuropathy and negative deep tendon reflexes. Infectious and malignant involvement were excluded with cerebrospinal fluid cytology. Brain and spinal magnetic were normal. Reduced amplitude was found in nerve conduction studies in lower extremities, sensory and motor responses could not be obtained. F response was reduced. The findings supported Guillain-Barré syndrome. Physical examination showed mild paleness and lymphadenopathy in the right supraclavicular area. White blood cells: 20x10 9_{, C-reactive protein: 40 mg / L.Viral markers showed no}

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dacarbazine chemotherapy protocol was initiated. Intravenous immunoglobulin 2 g / kg treatment was administered. Partial recovery was observed and physical therapy continued.

Discussion: The association of paraneoplastic syndrome with lymphoma is rare. When these syndromes

show association with tumor or onco-neuronal antibodies are detected, diagnosis of paraneoplastic syndrome can be made.

Take home message for practice: Early recognition is important as a delay in treatment.

Keywords. Lymphoma, cancer, neuropathy, weakness. Conflict of interest / Interessenkonflikte

no / nein

ePoster

Ordinary lumbar pain: Not everything is as it seems.

Irina Hernández Medina, Ester Ras Vidal, Elisabeth Tapia Barranco, Ana Isach Subirana, Josep Balsells Ghiglione, Ana Urbaneja Díez, Teresa Mauri Rojals, Gabriela Gutiérrez Ferriz, Pablo Hsu Chung, Sara Gómez Aranda

Reus-2, Sant Pere Primary Care Centre, Institut Català de la Salut, Reus, Spain

Background: 48 years old man, without allergies, and smoker of 15 cigarettes per day. No chronic

medication. He presented a single episode of right renal colic five years ago with normal ultrasound study. He consulted because of a new episode of right lumbar pain, without radiation, for 24 hours. Without fever nor more symptoms.

Questions: Which is the differential diagnosis in this case? Does he present any alarm sign?

Methods: He had right costovertebral angle tenderness to fist percussion and the rest of examination was

normal. Abdominal X-ray was performed, without findings. Urine analysis showed haematuria. Considering initial diagnosis of renal colic, analgesics were prescribed and the patient was awarened about alarm symptoms.

Outcomes: Two days later he consulted again because of fever and asthenia. Examination shows axillary

temperature 38.7 °C and auscultation of crackles in the right pulmonary base. The chest x-ray reveals right basal pneumonia.

Discussion: Renal colic pain is a frequent consultation in Primary care and emergency department. In this

case we can see how a clinical symptom that we usually associate with renal colic results in pneumonia. Since there is no alarm sign we can inform the patient about them and advise him to come back for medical evaluation.

Take Home Message for Practice: Since 10% of cases with this symptom may not be related with renal

lithiasis, we must be very cautious and make a wide and complete differencial diagnosis. We should keep in mind aortic disease, digestive and respiratory pathology.

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ePoster

What eosinophylia can reveal

Irina Hernández Medina, Ester Ras Vidal, Elisabeth Tapia Barranco, Isabel Sánchez-Oro Vallés, Ana Belén Castellví Margalef, Arantxa Osés Viñas, Xavier Floresví Aubia, Joan Boj Casajuana, Marina de la Torre Trillo, Carles Perpiñán Auguet

Background: 72 year old man, without allergies. He suffered from hypertension and was taking enalapril

50mg/24hours. Nonsmoker. He consultated because of asthenia for two months. He did not present toxic syndrome nor other clinical symptom. His general aspect was good and he was not on fever.

Questions: How should we approach to the diagnosis? Is it necessary to ask for any complementary test? Methods: Blood test revealed normal glucose level, liver and kidney function. Blood count of leukocytes was

20.31x10^9/L and eosinophils were 11.57x10^9/L. Also, a stool study was performed.

Outcomes: Stool culture was negative, but serial parasite stool studies revealed an intestinal infection by

askaris lumbricoides. The patient was treated with mebendazole 100mg twice a day for three days and it was repeated three weeks later. After 15 days we performed a blood test. The results were 10.5x10^9/L leukocytes and 1.5x10^9/L eosinophils. Finally, three months later the blood count was normal.

Discussion: Non-specific symptoms are challenging for physicians. To do a basic check-up can help us in

order to rule serious pathologies out. That includes blood test, stool test and x-ray if necessary. Eosinophilia as a biological sign of parasitic disease can occur in helminthiasis and also in some protozoosis.

Take Home Message for Practice: Always ask for complementary test if necessary. Eosinophilia is a

frequent consult in primary care and we must always keep it in mind. Conflict of interest / Interessenkonflikte

no / nein

ePoster

New oral anticoagulants prescription in primary care in Spain: from research to daily clinical practice.

Irina Hernández Medina, Ester Ras Vidal, Elisabeth Tapia Barranco, Isabel Sánchez-Oro Vallés, Ana Belén Castellví Margalef, Arantxa Osés Viñas, Xavier Floresví Aubia, Joan Boj Casajuana, Marina de la Torre Trillo, Carles Perpiñán Auguet

Background: New anticoagulants are changing the anticoagulation treatment panorama due to their easy

posology and efficacy.

Discussion Point: Evaluate new oral anticoagulants (NACO) prescription in a Primary care centre.

Content: Cross-sectional observational study in an urban primary care center. Patients over 18 years old

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and adequacy of the prescription based on recommendations of the Spanish Agency of Medications and Health Products (AEMPS).

Results: 147 patients. Mean age was 75.6 and 51% were women. 33.40% were treated with both NACO

and AVK drugs. 84,4% suffered from hypertension. Mean value of Charlson Index was 5.5 with a 10-year survival of 29.7%. Significant difference was observed in alcohol consumption, myocardial infarction and diabetes according to sex. Men were at a higher risk. Most prescribed NACO was dabigatran (36.7%), with a mean duration of 33 months. Polypharmacy average value: 7.6 drugs. Chad2Vasc average score: 3.7. Indication of prescription was non-valvular atrial fibrillation (NVAF) in 85% of cases and in 82,3% the prescriber was a medical specialist. Acenocumarin was previously used in 27.2%. Main reason for change were poor INR control (9.8%), a non-collaborative and unsupervised patient (4.8%) and adverse effects (6,1%). We detected an inappropriate use of NACO in 13.6%.

Take Home Message for Practice: Family doctors should carry out an exhaustive control of these patients

in order to detect wrong management as soon as possible. Conflict of interest / Interessenkonflikte

no / nein

ePoster

Multiple myofascial pain syndrome.

Iker Sierra-Martínez1)_{, Leticia Sierra-Martínez}2)_{, Rosario Martínez-Fuerte}3)_{, Natalia Sanz-González}4)

1)_{Traumatology Department, Hospital Comarcal, Medina del Campo, Spain} 2)_{Valladolid Este Primary Assistance Gerency, Sacyl, Valladolid, Spain}

3)_{PILARICA Health Center, Valladolid Este Primary Assistance Gerency, Valladolid, Spain, Valladolid, Spain} 4)_{Parquesol Senior Center, JCyL Social Services Gerency, Valladolid, Spain}

Reason For Consultation

68 year old patient with L5 - S1 lumbociatica, who comes to our office for pain control.

Personal History

Intolerance to buprenorphine, tapentadol, pregabalin, gabapentin, tramadol. Surgical interventions: Left knee prosthesis.

Treatment in the first consultation. He has been given metamizole, dexamethasone, dipotassium clorazepate, nabumetone, omeprazole.

Current Illness

Pain from cervical to sacrum to right, chronic, but now sharpened, mechanical type and puncture. It radiates to right leg. Thigh, knee and leg on foot. He notes hypoesthesia type that has partially recovered, neuropathic type pain.

The pain wakes him at night. He walks with a crutch for the prosthesis of the left knee.

Physical Exploration

Lassegue and Bragard Positive

Supplementary Tests

Lumbar magnetic resonance:

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Slight reduction in the size of the central spinal canal at level L4-5, of multifactorial origin. A moderate reduction of the bilateral foraminal caliber in L4-5, moderate / severe and of right predominance in L5-S1 is also observed.

Diagnostic Orientation

Lumbar disc protrusions. Lumbar degenerative changes

Multiple myofascial pain syndrome. Right pyramidal

Treatment Plan

-Rehabilitation.

-Infiltration of painful points.

-hydromorphone Hydrochloride 4mg / 24 hours + Duloxetine 30 mg / 24 hour

Conclusions

Myofascial pain syndrome is commonly treated by primary-care physicians, including family medicine doctors, general practitioners, and internists. Other physicians who treat myofascial pain syndrome include physiatrists, orthopedists, and rheumatologists.

ePoster

Group health education and polyarthralgia.

CLINICAL CASE:

Woman of 52 years, with: 1-diagnoses of:

a- Cervicodorsalgia.

b.-Low back pain, lumbar spondyloarthrosis with foraminal stenosis L3-L5. c- Right subtalar arthritis.

d- Constipating osteitis of the iliac. e- Idiopathic vertebral hyperostosis. 2. Current problem: Polyarthralgia. 3-Treatment:

•Medication: Tramadol 37.5 mg, paracetamol 650 mg every 8 hours according to the guidelines. If joint inflammation occurs use Naproxen 500: 1-2 times a day (use Omeprazole only if dyspepsia). The patient, not improved, the evaluation on the Visual Analog Scale (VAS) is 8.

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in the evaluation on the Visual Analog Scale (VAS) moving to the value of 2. 4-Conclusions:

Participation in health education activities significantly improved quality of life, decreased disability,

catastrophism and fear of movement, and also managed to significantly reduce the intensity pain and drug use.

5-Bibliography:

1.Mies Richie A, Francis ML. Diagnostic approach to polyarticular joint pain. Am Fam Physician. 2003 Sep 15; 68 (6): 1151-60.

2.Samantha J, Kendall J, Samantha A. Polyarthralgia. BMJ. 2003 Apr 19; 326 (7394): 859.

3.Klinkhoff A. Rheumatology. Diagnosis and management of inflammatory polyarthritis. CMAJ 2000; 162: 1833-8.

4.Galán Martín MA, Montero Cuadrado F. Educación en neurociencia del dolor. Una nueva visión. Dossier para pacientes.

ePoster

Evaluation of quality indicators for patients with chronic obstructive disease (COPD) in Primary Care.

Leticia Sierra-Martínez1)_{, Rosario Martínez-Fuerte}2)_{, Natalia Sanz-González}3)

1)_{Valladolid Este Primary Assistance Gerency, Sacyl, Valladolid, Spain}

Background & Aim

Study of the quality of the registration of chronic obstructive disease (COPD) screening patients assigned to a Health Center (HC) and compare them with patients with HF with the health area (HA) and patients in the Autonomous Community of Castile and León (CyL) (during the 2018).

Method

Design: Longitudinal evaluation: Palmer’s Quality Cycle Setting: An urban health care center.

Population and Sample: EPOC patients ≥ 14 years. Interventions:

-Internal evaluation, dimensions:scientific-technica, quality, adequacy, accessibility, continuity of care; data related to the care process and intermediate results; explicit, evidence-based procedural criteria. Subjects: analysis of coverage. Analysis on the evolution of treatment compliance. The Z statistical test for

comparing proportions, alfa 0,05.

Results

Compliance criteria (year 2018):

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% COPD-Spirometria: HC 8,21%, HA 14,42%, CyL 11.65% % COPD-flu vaccine: HC 59,29%, HA 61,77%, CyL 61.93%

% COPD-pneumococcal vaccine: HC 61,43%, HA 61,88%, CyL 62.02% % COPD and anti-smoking advice: HC 4,26%, HA 12,28%, CyL 5.6 4. Conclusions:

The analysis of the records of the screening indicators for patients with COPD makes us aware of the importance of patient control.

Registration allows us to evidence improvements in the care process.

To make a good registry of the controls, to adapt the interventions with the patient, adapting them to each case.

After our analysis we say that we must improve the recruitment of patients with COPD and the quality of the records of the care process.

Lecture / Vortrag

Derterminants of effectiveness of AF case-finding in primary care

Juan Ballesta Ors, Eulalia Muria Subirats, Blanca Lorman Carbo, Francisco José Sánchez Galindo, Josep Lluis Clua Espuny

Primary Care, ICS Institut Catala de la Salut, Tortosa, Tarragona, Spain, Spain

Background: atrial fibrillation (AF) is often asymptomatic and screening is not routinely undertaken. Objective: evaluate the feasibility and effectiveness of a population-based case-finding program and to

identify the enablers or barriers for its implementation.

Methods: Cross-sectional study of a health care case-finding program for AF (from 01/01/2016 to

31/12/2017) that included 48336 people ≥60 years in the region of Terres de l’Ebre (Catalonia, Spain). We analyzed the effect on the prevalence of AF and, stratified by age, on the incidence of new diagnosed AF. We assessed the sociodemographical and clinical variables related to the realization of opportunistic screening.

Results: 32090 (62.4%) people were screened for AF. We observed a significant increase in the AF

prevalence after 2 years of program intervention (5.9% to 7.7%, p <0.001). The detection of new AF cases was significantly higher in the screening group across the whole of the age range. 765 (2.6%) new AF cases were diagnosed using opportunistic screening.

Age ≥70 years, semi-urban residence, institutionalized status, Pfeiffer score ≥2, Charlson score >3, and number of visits ≥7/year were significantly associated with having opportunistic screening.

Conclusions: A health care program of case-finding is feasible and it is associated with a significant increase

in the prevalence and incidence of AF. The results depend on factors such as the ease of access to health care, age, place of residence and comorbidities.

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Lecture / Vortrag

Relationship between AF-risk, ischemic stroke AF-related, and cognitive dysfunction in population ≥65 year-old. MIND-COR Study.

Juan Ballesta Ors, Eulalia Muria Subirats, Blanca Lorman Carbo, Josep Lluis Clua Espuny, Anna Panisello-Tafalla

Primary Care, ICS Institut Catala de la Salut, Tortosa, Tarragona, Spain, Spain

Background:

The number of individuals with atrial fibrillation (AF) and cognitive impairment (CI) will increase 150% by 2050.

The main objective of this study is to elucidate the relationship between AF-risk, the ischemic stroke, and the cognitive dysfunction.

Methods:

Multicenter, longitudinal and retrospective community-based study of cohort ≥65 year-old without AF between 1/1/2013-31/12/2017 conducted by 11 Primary Care teams. Variables: sociodemographic; Charlson, CHA2DS2VASc score, Pfeiffer and NIHSS scores from records database (primary care, specialty clinics and

hospitalizations). Kaplan-Meier to evaluate mortality.

Descriptive analysis. Cox regression to create an AF risk score was developed: Q1 (lowest AF-risk)-Q4 (highest AF-risk). Incidence density (ID) rate per 1000/people/years of AF and stroke; and CI prevalence were calculated by risk stratum.

Results:

46706 (women 49%) cases, aged 78.01±11.9 and average follow-up time 4.9±0.7 years. Q4 risk group (Q4) was characterized by women’s (85.2%), highest age, AF, stroke, CI and mortality.

1244 AF were diagnosed (ID 10.5/1000/year’s IC95% 9.9-11.2). Q3-4 levels included 53.8% AF in men vs 84.2% in women. 214 strokes were diagnosed and 78.5% happened in Q3-4, especially among women (88.1%). The stroke and AF were diagnosed simultaneously in 9.8% (ID 5.8/1000/year CI95% 3.4-8.1) and showed higher severity (NIHSS 7.25±8.62 vs 4.55±5.74, p=0.002). Cognitive impairment increased 2.6% (Q1) to 16.4% (Q4) significantly higher in women (17.6% vs 12.1%)

Conclusions:

Differences were found according to gender and risk groups. The risk-based screening could improve the effectiveness of AF screening in primary care.

ePoster

Hemianopsia and multiple sclerosis.

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2)_{Valladolid Este Primary Assistance Gerency, Sacyl, Valladolid, Spain}

Woman, 34 years old, smoker, family history of autoimmune diseases. In our consultations since June 2012, that his illness, with 5 weeks of pregnancy of his first child, in the form of heteronymous hemianopsia, without eye pain. Magnetic resonance imaging (MRI) showed normal pituitary gland and hyperintensity of both optic nerves to the chiasma, with some small juxtacortical lesion. This clinic remained stable, with fluctuations during the first months and was postponed to complete the study until the end of pregnancy. Due to the atypicality of the condition, a diagnosis was not initially established and we followed the patient

in our consultations. MRI (March 2014) unchanged from the previous one.

Clinically, the alteration had disappeared and the neurological examination was normalized. He presented oligoclonal bands in CSF and the rest of the immunological and serological study

was negative. AQP-A4 negative antibodies.

She remained clinically and radiologically stable, with MRI in 2015 and 2017 unchanged, with a new pregnancy in 2014 without complications.

In October 2019 consultation by trunk clinic, MRI (10/7/2019) showing 4 new lesions, two active, compared to 2017.

I received steroidal treatment and have improved.

Exploration: Normal cranial pairs. There is no motor or non-sensitive deficit. Romberg and unstable tandem. DIAGNOSTIC: Patient who meets time and space dissemination criteria for multiple sclerosis. It has presented two outbreaks, in June 2012 and in September 2019

PLAN: It is proposed for treatment and the different options are presented, jointly opting for dimethyl fumarate and healthy lifestyle plan.

Workshop

Differential diagnosis: an educational board game

Norbert Donner-Banzhoff, Stefan Bösner, Matthias Michiels-Corsten, Annette Becker

Abteilung für Allgemeinmedizin, Präventive und Rehabilitative Medizin, Philipps-Universität-Marburg, Marburg, Germany

Background: Learning about the diagnostic process preferably takes place in practice. However, there are

often limitations regarding time, logistics and the availability of suitable patients. When teachers construct cases, these often suffer from being too typical and implying a definite solution, contrary to the problems presented by real patients.

Target group: General Practice educators, doctors in training, GPs

Methods: We have developed a board game simulating the diagnostic process in generalist settings, such

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prioritization of diagnostic information, action thresholds, costs, when to stop gathering data etc. As diagnostic information comes in, participants discuss their value regarding relevant hypotheses. As in real life, cases do not always have a clear solution. The game shows the uncertainty pervasive to the diagnostic process. At the same time, it is highly entertaining and funny.

Format: Participants will play the game in two parallel groups (English and German).

Objectives: Participants learn the objectives and rules of the game. They become familiar with concepts

relevant to making a diagnosis in generalist settings.

Number of participants: 15 + 15

Presenters: Presenters are affiliated with the Department of General Practice at the University of Marburg.

Diagnosis in primary care has been a research and teaching focus for 15 years Conflict of interest / Interessenkonflikte

no / nein

ePoster

Prevention of fragility fractures

A 70-year-old female patient who goes to the emergency department after suffering a fall at home. It refers to pain at rest and to the mobilization in the lower right limb at the level of the upper femur. Shortening of

the right leg and external rotation is observed. Functional impotence

AP radiograph of right femur and hip showing pertrochanteric fracture. Enter with the diagnosis of right pertrochanteric fragility fracture to perform surgery. and is surgically operated performing reduction and osteosynthesis with endomedular nail of proximal femur.

Conclusions:

Fragility fractures are quite frequent, and postoperative ones can be longer and more complicated than normal, which makes patients bedridden or with reduced mobility, which unfortunately will enhance that osteoporosis and bone weakness.

Be aware of risk factors associated with fragility fractures, such as age, having had a previous fragility fracture, family history (of osteoporosis or fragility fractures), great weight loss, or treatment with corticosteroids chronically Also being a woman, or an early menopause are risk factors, which in our case are present.

Very important, as always, to make a good medical history and physical examination, being able to suspect nutritional deficits, low physical activity of the patient, or vertebral crushing and hypercifosis characteristic of vertebral crushing due to bone fragility. The doctor, assessing these risk factors, can suspect an osteoporosis or a risk of fracture of high fragility, being able to request densitometry or calculating an FRAX in consultation.

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no / nein

ePoster

Multiple myeloma in pregnancy

Diana Gonçalves1)_{, Humberto Gonçalves}2)

1)_{Tortosendo Primary Health Care Unit, Covilhã, Portugal}

2)_{The Cova da Beira Hospital and Universitary Centre, Covilhã, Portugal}

Background:

Hematological malignancies as multiple myelomas (MM) are rare in women and exceptionally rare in pregnancy.

Questions:

Can we suspect of a Multiple Myeloma in pregnancy?

Methods:

Case description based on medical records and literature revision of all previously published cases on PubMed database in English, with MeSH terms “Multiple Myeloma” and “Pregnancy”, resulting in 7 articles, corresponding to 43 reported cases.

Outcomes:

A 35-year-old patient was followed during her pregnancy in primary care without any complications. She presented a mild microcytic and hypochromic anemia in the second trimester and oral iron supplementation was initiated. At 38 weeks of gestation, the patient went into labor, giving birth to a healthy child. The persisting anemia of the postpartum raised suspicion and the diagnose of Multiple Myeloma IgG K was established 2 months after delivery. She was admitted to the hospital to initiate treatment and on her fourth day of hospitalization, she passed away due to a pulmonary embolism. She was always very reluctant to the idea of being hospitalized and that may have delayed the diagnosis.

Discussion:

Owing to the few cases reported, there are no specific orientations to the management of this condition neither is known what influence pregnancy might have on the disease progression. MM symptoms are very similar to those of normal pregnancy: asymptomatic proteinuria, anemia, and fatigue, which usually do not raise concerns from physicians.

Take Home Message for Practice:

To think the unthinkable to achieve better outcomes for both mothers and newborns. Conflict of interest / Interessenkonflikte

no / nein

Case presentation by young doctors / Fallvorstellungen von junge Ärzte/innen

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Gabriela Machado1)_{, Yuliya Kuzmyn}1)_{, Joana Afonso}1)_{, Ana Marinho}2)_{, Diogo Prates}3)_{, Filipe Mateus}4)_{, Mara}

Silva5)_{, Marta Freitas}2)_{, Ricardo Coelho}6)_{, Ana Valério}1)

1)_{USF São João do Pragal, Almada, Portugal} 2)_{USF Cova da Piedade, Almada, Portugal} 3)_{USF Pinhal de Frades, Seixal, Portugal} 4)_{USF Cuidar Saúde, Seixal, Portugal} 5)_{USF Poente, Almada, Portugal} 6)_{USF Feijó, Almada, Portugal}

Venous thromboembolism (VTE) is an important cause of cardiovascular incapacity and mortality. Annual incidence of VTE is 1-2/1000. The most important risk factor is the previous history of deep vein thrombosis (DVT), which increases the risk of a new episode in 25%.

We present the case of a 37 year-old female patient, previously healthy, recently registered in our Primary Health Care Unit, who requested a warfarin prescription. We booked an appointment and discovered a serious of previous hospitalizations because of DVT of the left lower limb and pulmonary thromboembolism (PTE) that had begun at the age of 24. In one of those episodes the diagnosis of May-Thurner Syndrome was made. The investigation for thrombophilias was negative. Presently the patient is under oral anticoagulation with warfarin.

May-Thurner Syndrome consists in the compression of the left common iliac vein by the right common iliac artery. According to the literature it is present in 18 to 49% of the cases of left lower limb DVT. As such, in the presence of a left lower limb DVT wihout a known cause, this syndrome must be excluded. With this case report we pretend to emphasize the importance of the general practitioner in the study of patients with DVT to identify secondary causes of this disease, in order to prevent new events. Furthermore, this case also shows the value of the first contact of the physician with the patient, concerning the global approach to the patient’s health.

Lecture / Vortrag

Quality and safety significant event analyses-a prerequisite to quality improvement?

David Moores, Mirella Chiodo

Family Medicine, University of Alberta, Edmonton, Canada

Background: Since 2013 the Department of Family Medicine, University of Alberta has required its Family

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U.K. based initiative-TVC's Patient Safety in Primary Care, for all residents and faculty. Outcomes: The two fundamental pillars of the program are quality and safety educational content and the processes of identifying and analyzing significant events in clinical practice. To date over seven hundred significant events have been identified and subjected to analysis. Family Medicine Residents and practice staff are encouraged to utilize significant event analysis as a platform for quality improvement initiatives in their practices. Conclusion/Take Home Message: The addition of a family practice/primary care focus allows more inclusive opportunities to learn of the quality and safety challenges and QI opportunities of integrating health services. Such analyses provide a rich addition to conventional quality improvement initiatives. Conflict of interest / Interessenkonflikte

no / nein

1 Slide – 5 minutes lecture / 1 Abbildung – 5 Minuten Vortrag Secundary lesions due to porphyria cutanea tarda

Rita Maia, Maria Jesus Clara

USF "A Ribeirinha", Guarda, Portugal

Background: Porphyria Cutanea Tarda (PCT) is the most common form of porphyria. It results from a

deficient uroporphyrinogen discarboxylase enzyme (URD) in heme synthesis pathway and consequent accumulation of porphyrins in skin, liver and blood. There is usually a triggering factor: alcohol, viral infections (hepatitis B and C and HIV), iron overload, which causes inhibition of URD activity. The main cutaneous manifestations are photosensitivity, vesicles, blisters, hyperpigmentation and hypertrichosis in the photo exposed areas.

Discussion Point: Discriminate different skin lesions and their pathologies.

Case Report (Content): A 52 years old male, was referred to Dermatology department due to erosions

and crusting on face with 2 years evolution. He also presented these lesions on the back of the hands with forearm extension surfaces, associated with hypertrichosis and marked photo aging on face. He had clinical background for alcoholism, untreated hepatitis C and heroin addiction. A blood test reveals abnormal liver function, increased urine porphyrins, ferritin elevation and heterozygous H63D mutation in HFE hemochromatosis gene. He was diagnosed with PCT. After treatment with phlebotomies, low-dose hydroxychloroquine and photoprotective he was referred for hepatitis C treatment. The last flow up revealed gradual resolution his lesions.

Take Home Message for Practice: Skin is the largest organ in our body and through it, we can diagnose

different diseases when other symptoms are absent. General practitioners should know different cutaneous presentations for early diagnosis and treatment of trigger causes, avoiding serious complications.

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Metastatic tumor of unknown primary origin: a case report

Patrícia Figueiredo, Patrícia Gouveia, Ana Cristina Prata, Ana Cristina Vitorino, Patrícia Santos, Paulo Mata

USF Sobreda, ARSLVT - ACES Almada-Seixal, Sobreda, Portugal

Background/Questions: Cancer of unknown primary (CUP) is a malignant widespread metastatic disease

without an identifiable primary site after extensive clinical investigation. CUP is the third to fourth most common cause of death due to cancer-related mortality. High risk for developing CUP is seen in heavy smokers.

Methods: Qualitative description of case reported.

Outcomes: A 62-year-old man, ex-smoker, was observed in our consultation due to a right submandibular

mass. At the initial visit, the mass was covered by reddened skin and was elastic, hard, and immobile on palpation. The presence of malignant disease such malignant lymphoma or cervical lymph node metastasis was suspected on basis of the clinical and neck computed tomography (CT) imaging findings. The patient was referred to secondary care for diagnosis and treatment. Whole-body positron emission tomography (PET) demonstrated abnormal accumulation in the right cervical and aortopulmonary lymph nodes and showed pulmonary, abdominal, pelvic and osteomedullary lesions. Resection of cervical mass, adenoidectomy and tonsillectomy were performed. Histopathological examination revealed cervical lymph node metastasis of undifferentiated squamous cell carcinoma. Whole-body CT were performed to locate the primary cancer, but its origin remained unknown. Postoperative therapy consisted of chemotherapy, with good response after 6 cycles of treatment.

Discussion/Messages: The diagnosis and treatment of CUP are challenging due to its late presentation,

difficulty in diagnosis, and therapeutic resistance. Comprehensive medical history and complete physical examination are crucial. Strategies need to be developed to expedite the diagnosis of cancer and avoid unnecessary delays in treatment.

ePoster

Urinary sediment microscopy

Peter Sigmund

Ordination, STAFAM Steirische Akademie für Allgemeinmedizin (Styrian academy for familiy medicine), Gamlitz, Austria

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Erythrocytes as well can be easily visually detected, instead of relying on failure-prone chemical reactions. In addition, urinary microscopy allows us to see other physiological as well as pathological components like bacteria, cylinders, crystals, kidney cells or trichomonads.

The poster explains the diagnostic aspects as well as the preparation of urinary sediments, and shows corresponding microscopic images, which can also be seen in a QR-linked video.

Case presentation by young doctors / Fallvorstellungen von junge Ärzte/innen

Case presentation: lymphadenopathy, splenomegaly, pancytopenia and epstein-barr virus

Bekir Aktura, Nilüfer Aktura

Güneştepe Family Medicine Center, Güngören/Istanbul, Turkey

Background:

General practitioners encounter the vast majority of patients with Epstein-Barr virus-related disease, i. e. infectious mononucleosis in children and adolescents. But the Epstein-Barr virus (EBV)-pancytopenia is a rare entity in the spectrum of lymphoproliferative diseases associated with the EBV.

Case:

9 -year-old girl is brought to the family physician by her mother because of swelling in her neck. Her mother had just noticed. Fever and pharyngitis were not present. Multiple submandibular lymphadenopathy and splenomegaly were detected. Complete blood count revealed pancytopenia: (Hemoglobin: 11.4 g/dl, Platelets:76000 White Blood Cells:3630) Patient referred to the tertiary center and in there, EBV DNA was positive. Bone marrow biopsy and aspiration were also performed and bone marrow was normocelular. At the end of the 6th day, the patient was discharged from tertiary center. Now the girl is completely healthy who is still under control by family physician and the tertiary center. It has been two months after the disease by now.

Conclusion:

Although EBV related pancytopenia is rare; EBV infection seems frequent in family medicine practice. While presenting to this uncommon case, we aimed to review EBV and related diseases in primary care.

1 Slide – 5 minutes lecture / 1 Abbildung – 5 Minuten Vortrag Two cases of an unusual diabetes

Joana Bragança1)_{, Filipa Órfão}2)_{, Marina Lima}1)_{, Célia Pinheiro}1)

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Background:

Latent autoimmune diabetes in adults (LADA) is a disease in which, despite the presence of autoantibodies against pancreatic beta cell antigens (ICA) at diagnosis, the progression to insulin dependence is heterogeneous. Usually, patients are aged between 30 and 50, have family or personal history of autoimmune disorders, normal BMI and hyperglycemic symptoms with increased risk of ketoacidosis.

Case report:

We present two cases of LADA.

The first patient is a woman aged 67 that presented with fatigue and weight loss. Endoscopic exams were requested but revealed no findings. Later the patient referred polydipsia and blood work showed a glycemia of 260mg/dL. Glargine was prescribed and ICA requested. These showed positive titters and the patient initiated an intensive insulin scheme.

The second patient is a woman aged 47 that resorted to the ER with altered mental status. Blood work showed a glycemia of 383mg/dl and pH of 6.5. She referred weight loss, polydipsia and polyuria and glargine was prescribed. Her physician latter requested ICA which showed positive titters. An intensive scheme of insulin was initiated.

Discussion:

Given the presence of hyperglycemic symptoms, weight loss and the swift progression to insulin dependence with a normal BMI, we made the presumptive diagnosis of LADA in both cases. The first case is unusual because it occurs in an elderly patient and the second shows ketoacidosis as the inaugural presentation. Because LADA is a heterogeneous entity, the practitioner should be aware of its main features to make the diagnosis and appropriate treatment.

Workshop

Major end-of-life symptoms in family medicine: consensus workshop for optimal assessment and treatment

Jean-Claude Leners

General Medicine, Long Term Care and Hospice Care, Ettelbruck, Luxembourg

Background:

End of life symptoms may be sometimes challenging in family medicine as they can occur unpredictably and a rapid assessment and treatment is needed

Target group:

All family doctors will accompany at least several times a year some of their patients until end of life, as this is part of the core business for general practitioners. This means that the management of some relevant symptoms is important to know.

Didactic Method:

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threats and opportunities of these. Three case reports (3 times 45 minutes) out of the daily hospice practice will help us to illustrate the treatment options.

Objectives:

It should be possible by end of the workshop to resume in a concise manner our common way of handling in regard of the following three symptoms: anxiety, agitation and delirium. We will include non-medical and medical aspects.

Estimated number of participants:

In order to give all colleagues the opportunity to participate actively in the workshop, the number should probably not exceed 25 or 30 participants

Workshop leader:

He is since 38 years an active family doctor, working part-time in a hospice with 3 other colleagues, all of them also general practitioners.

ePoster

Waiting for Sjögren

Helder Sousa, Nuno Teles Pinto, João Teles

USF Fânzeres- ACeS de Gondomar, Porto, Portugal

Background: Sjögren syndrome (SS) is a systemic chronic autoimmune disorder, characterized by dryness

of the mouth and eyes, and often these are the initial complaints posed to family physician. Diagnosis is made by specific clinical criteria (specially the American-European classification criteria), autoantibodies, and histopathology. However, not every patient with the diagnosis of SS fulfills the proposed criteria.

Case report: 80-year-old woman with personal history of hypothyroidism, type 2 diabetes mellitus and

depression. The patient presented in 2016 to the family physician with complaints of xerostomy and xerophthalmia since a year ago. Medicated with pilocarpine, improving xerostomia. The autoimmunity study showed positive alpha-fodrin autoantibodies. Due to suspected SS the patient was endorsed to an internal medicine consultation: scintigraphy of the salivary glands was compatible with SS. The salivary gland biopsy was classified on grade 2 in the classification of Chisholm-Manson. In view of these results, the patient does not meet (yet) diagnostic criteria for SS, maintaining annual surveillance and pilocarpine.

Comment: Like many rheumatic diseases, which presents a dynamic nature, the fulfillment of the diagnostic

criteria of SS may not be met at the beginning of symptomatic presentation. However, the patient's symptoms and complaints, even if not fully frameable in a pathological entity, need to be valued by the family doctor. In the case previously described, and although the diagnosis of SS is not yet certain, a therapeutic strategy guided by the patient's complaints and not by a potential diagnosis was adopted, which represents an holistic and patient-oriented practice.

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ePoster

Breast cancer “out of sight”: a primary carcinoma of axillary accessory breast case report

Gabriela Machado1)_{, Yuliya Kuzmyn}1)_{, Joana Afonso}1)_{, Ana Marinho}2)_{, Diogo Prates}3)_{, Filipe Mateus}4)_{, Mara}

Silva5)_{, Marta Freitas}2)_{, Ricardo Coelho}6)_{, Teresa Calheiros}1)

1)_{USF São João do Pragal, Almada, Portugal} 2)_{USF Cova da Piedade, Almada, Portugal} 3)_{USF Pinhal de Frades, Seixal, Portugal} 4)_{USF Cuidar Saúde, Seixal, Portugal} 5)_{USF Poente, Almada, Portugal} 6)_{USF Feijó, Almada, Portugal}

Ectopic breast tissue has been reported to occur in about 6% of the population. Primary carcinoma of ectopic breast tissue is rare, representing 0.3% of the cases of breast cancer, and is considered to have a worse prognosis than the carcinoma of the anatomic breast. The axilla is the most frequent site of the primary tumour.

We present the case of a 62 year-old female woman with a personal history of papillary thyroid carcinoma (she underwent a total thyroidectomy 10 years before), and with no family history of breast carcinoma. She consulted her general practitioner after noticing a lump in her left arm, near the axilla. Physical examination showed a non-tender mass measuring 1.5 cm in diameter, which was interpreted to be a lipoma. For cosmetic reasons she underwent excision of the mass by a dermatologist and the histological examination of the specimen showed infiltration of the subcutaneous tissue by a ductal carcinoma of the breast, with the margins positive for neoplastic cells. The breast MRI was normal. She underwent a second surgery to widen the excision and a sentinel lymph node biopsy was done, that revealed no malignant invasion. She is currently under adjuvant hormonotherapy and radiotherapy.

There is no difference in diagnosis and symptoms of ectopic breast carcinoma compared with carcinoma of the anatomic breast. With this case we pretend to emphasize the importance of considering this disease in the differential diagnosis of axillary masses in General Practice.

ePoster

Recurrent Pneumonia

Victoria Romero Portero1)_{, Rocío Espejo Torres}1)_{, Teresa Benedito Pérez de Inestrosa}2)

1)_{Family and Community Medicine., C.S Puebla de Vícar, Distrito Poniente., Puebla de Vícar, Almería., Spain} 2)_{Family and Community Medicine., C.S Las Norias de Daza, Distrito Poniente., El Ejido, Almería., Spain}

Background: 75-year-old patient with hypertension, type 2 DM, paroxysmal atrial fibrillation, severe OSA,

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left chest pain with cough and fever of 38ºC of 2 days of evolution. He has presented six hospital admissions in this year with diagnoses of left basal pneumonia and decompensated heart failure in all of them. In exploration: Good general condition, conscious, oriented, blood pressure 100/60, saturation 96% with O2, glucose level 128. Normal ECG. Neurologically: Dysarthria and dysphagia, hemiparesis in the right hemibody. Cardiorespiratory: Arrhythmic at 75 bpm, no murmurs, hypoventilation in the left pulmonary base. Methods: Leukocytosis (20,800 µL) with neutrophilia (81.5%) in analytical. A left pleural effusion is seen on the chest plate. Discussion: In view of the numerous admissions, with involvement in all of them of the left lung, we requested pulmonary CT with contrast, finding a radiopaque foreign body of 14 x 8 mm in the bronchial lumen. Outcomes: The patient was referred to the rigid bronchoscopy unit in Granada, where the foreign body that was lodged in the left main bronchus was removed. It was a chicken bone. Take Home Message

for Practice: In the approach of a case of recurrent pneumonias limited to a particular anatomic region, we

have to send imaging technique to rule out anatomical abnormalities or for example, the presence of foreign bodies.

ePoster

Doctor, I can't speak correctly

Victoria Romero Portero1)_{, Teresa Benedito Pérez de Inestrosa}2)

1)_{Family and Community Medicine., C.S Puebla de Vícar, Distrito Poniente., Puebla de Vícar, Almería., Spain} 2)_{Family and Community Medicine., C.S Las Norias de Daza, Distrito Poniente., El Ejido, Almería, Spain}

Background: 83-year-old patient with a history of clear cell nodular melanoma stage IIIB (left axillary

clearance in 2017), who consulted for a clinical picture of paresthesias in the tongue and in the right commissural area of 1 day of evolution with associated right hemicraneal headache and dysarthria. Despite her age, she is a patient in an optimal state, both physical and intellectual. Totally independent for basic activities of daily life. Questions: In the exploration she presented good general condition, oriented, collaborative, afebrile, Glasgow 15/15, blood pressure 130/75. Neurologically with dysarthria, normorreactive isocoric pupils, preserved eye movements, symmetrical cranial nerves without alterations. No cervical stiffness or meningeal signs. Methods: The patient is reluctant to have a brain imaging test, but with her background and with the clinic she has, it is the most recommended thing to do. Outcomes: In CT scan of the head, several hyperdense nodular lesions with sizes between 8 and 25 mm are observed, suggestive of metastases. The patient in full mental faculties refuses any medical intervention and signs the voluntary discharge. Discussion: Although the patient refuses to be treated, the important thing in this case is knowing how to discern which patients need an imaging test and which patients do not. Take Home Message for

Practice: In any patient with a neoplastic history and with a neurological clinic, an imaging test must be

carried out so that a possible progression of oncological disease does not escape us. Conflict of interest / Interessenkonflikte

no / nein

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ePoster

Helicobacter pylori and Hyperthyroidism – fiction or reality

Ana Rita Costa, Andreia Gil Ferreira, Ana Nicolau Gomes, Raquel Monteiro

USF Tornada, Tornada, Portugal

Background: Hyperthyroidism is a disease caused by the excess of thyroid hormones, which may have

many different etiologies. Its presentation can be subtle or dramatic, with symptoms like palpitations, hyperhidrosis, fatigue, increased appetite and weight loss. We may also find tachycardia, a warm and moist skin, hand tremor and hypertension. Some studies have shown a correlation between auto-immune thyroid diseases and Helicobacter pylori infection. Patients with an auto-immune thyroid disease have a higher susceptibility to contract H. pylori and its eradication seems to reduce anti-thyroid antibodies.

Case-Report: 55 year-old woman, irrelevant personal medical history. Single parenthood family, stage VI

of the Duvall family cycle, Graffar III. She went to her Family Doctor with dysphagia, vomiting, dyspnea, globus sensation and thicker saliva feeling with one-week duration. She denied other symptoms. The patient did a Gastric Endoscopy which showed moderate degree gastritis and was medicated with esomeprazole. While awaiting the results for H. pylori search, the patient’s symptoms aggravated, which prompted a thyroid function evaluation and thyroid ultrasound. The diagnosis of hyperthyroidism with multinodular goiter and concurrent H. pylori infection was established. She was sent to an endocrinologist to perform a scintigraphy and be treated accordingly.

Conclusion: Both hyperthyroidism and H. pylori infection may produce unspecific symptoms. It is important to consider these diagnoses, for these diseases can have important long-term consequences. Studies have shown an association between auto-immune hyperthyroidism and H. pylori infection, which is why it is important to consider the occurrence of both at the same time.

ePoster

My hands are shaking – an approach to tremor in primary care

Patricia Ribeiro Santos1)_{, Cristina Prata}1)_{, Patricia Figueiredo}1)_{, Paulo Mata}1)_{, Rute Afonso}2)

1)_{USF Sobreda - ACeS Almada Seixal, Sobreda, Portugal} 2)_{USF Arandis - ACes Oeste Sul, Torres Vedras, Portugal}

Background and Questions: Tremor is the most common movement disorder encountered in primary

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Methods: Literature review through PubMed, from 2010 to 2019, using the MeSH terms “Tremor” and

“Diagnosis”.

Outcomes: Rest tremors occur in a body part that is relaxed and completely supported against gravity,

whereas action tremors occur with voluntary contraction of a muscle. All persons have low-amplitude, high-frequency physiologic tremors at rest and during action that can be enhanced by anxiety, medication use, caffeine intake, or fatigue. Features consistent with psychogenic tremor are abrupt onset, spontaneous remission, changing tremor characteristics, and extinction with distraction. The most common pathologic tremor is essential tremor; it is an action tremor, transmitted in an autosomal dominant fashion in one-half of cases, and affects up to 6 percent of the population. Tremor present in Parkinson disease is typically asymmetric, occurs at rest, and becomes less prominent with voluntary movement.

Discussion/Take Home Messages: Tremor is a frequent disorder, affecting up to 5% of people older

than 40 years old. It is thus essential that general practitioners can differentiate between different types of tremor.

Lecture / Vortrag

A tongue laceration in GP practice: whether to suture or not

Pim Keurlings

Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, Netherlands

Background/Question:

Severe tongue lacerations, usually from falls or epileptic attacks, are uncommon in GP practice. A mucous laceration of the oral cavity usually don’t require suturing and heals spontaneously. But what about tongue lacerations, as the tongue mainly consists of muscle? Whether to suture or not? GP guidelines are lacking.

Methods:

We performed a systematic search on PubMed and Google Scholar. Additionally we organized a consensus expert meeting with 12 Dutch and Belgian ENT-specialists (August 2019). During this meeting we proposed them the indications suggested in literature to suture tongue lacerations.

Outcomes:

We found only two retrospective studies with small cohorts and several methodological weaknesses. Using these we weren’t able to answer our question so we proceeded to unravel expert opinion. In the consensus meeting we found a striking agreement between ENT-experts. We achieved 7 unanimous consensus criteria in which a patient should be referred to an ENT-specialist for sutures. The remaining majority of patients doesn’t require suturing due to the tongue’s marked circulation and according healing and regeneration capacity. Experts recommend to (tele)consult them in case of doubts. Conservative treatment consists of wound flushing, cooling and avoidance of warm meals/drinks for one day.

Conclusion/Discussion:

There is no level I of II evidence to answer our question. We recommend our 7 Tongue Laceration Consensus Criteria (TLCC-7) as a guide for GPs. Most of tongue lacerations probably do not require suturing unless one of the TLCC-7 applies. Future research is needed to strengthen our findings.