Does the white coat influence satisfaction, trust and empathy in the doctor-patient relationship in the General and Family Medicine consultation? Interventional study.

OBJECTIVES: To understand the influence of the white coat on patient satisfaction, opinions about medical clothing, perception about confidence, empathy and medical knowledge and the satisfaction and comfort level of physicians in consultation. SETTING: An interventional study was conducted with a representative sample of the population attending primary care in central Portugal. PARTICIPANTS: The sample was composed by 286 patients divided into two groups exposed or not to a doctor wearing a white coat. The first and last patients in consultation every day for 10 consecutive days were included. INTERVENTIONS: Every other day the volunteer physicians consulted with or without the use of a white coat. At the end of the consultation, a questionnaire was distributed to the patient with simple questions with a Likert scale response, the Portuguese version of the 'Trust in physician' scale and the Jefferson Scale of Patient Perceptions of Physician Empathy - Portuguese Version (JSPPPE-VP scale). A questionnaire was also distributed to the physician. OUTCOMES: Planned and measured primary outcomes were patient satisfaction, trust and perception about empathy and secondary outcomes were opinion about medical clothing, satisfaction and comfort level of physicians in consultation. RESULTS: The sample was homogeneous in terms of sociodemographic variables. There were no statistically significant differences between the groups in terms of satisfaction, trust, empathy and knowledge perceived by the patients. There were differences in the opinion of the patients about the white coat, and when the physician was wearing the white coat this group of patients tended to think that this was the only acceptable attire for the physician (p<0.001). But when the family physician was in consultation without the white coat, this group of patients tended to agree that communication was easier (p=0.001). CONCLUSIONS: There was no significant impact of the white coat in patient satisfaction, empathy and confidence in the family physician. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov ID number: NCT03965416.

When the uterine mass is not a leiomyoma.

A 37-year-old nulliparous woman with abnormal uterine bleeding and a uterine mass suggestive of a leiomyoma not responding to medical therapy was submitted to two hysteroscopies with histological analysis. The first one showed a 'leiomyoma' and the second a 'uterine smooth muscle tumour of uncertain malignant potential/epithelioid leiomyosarcoma, with positivity for hormonal receptors'. The patient was submitted to a total hysterectomy with bilateral salpingo-oophorectomy, and the microscopic examination of the tumour revealed a 'uterine tumour resembling ovarian sex-cord tumours'. According to the literature, most cases are diagnosed in postmenopausal women and have a favourable prognosis. These rare tumours have uncertain malignant potential and have no established treatment protocol, but it appears that a fertility-sparing approach is possible once they are well diagnosed.

Peripheral blood pressure by Dinamap and central blood pressure by applanation tonometry in outpatient general practice.

INTRODUCTION: Central blood pressure (CBP) is the pressure exerted by the blood column at any given moment on the aortic and carotid artery walls, which is a close proxy for the blood pressure inside the brain and the heart, and is thus a better marker of cardiovascular morbidity and mortality than peripheral blood pressure (PBP). OBJECTIVE: To assess how the augmentation index (AI), peripheral pulse pressure (pPP), central pulse pressure (cPP) and subendocardial viability ratio (SEVR) vary in hypertensive patients according to level of control of CBP and PBP. METHODS: We performed an observational, cross-sectional study in a convenience sample from a general practice in Central Portugal over a period of four days in May 2010. Measurements were taken after a four-minute resting period. The following values were considered to reflect controlled pressures: PBP <140/90 mmHg, CBP <130/80 mmHg, pPP <55 mmHg and cPP <45 mmHg. RESULTS: The sample included 92 patients, 38 male (41.3%), mean age 62.3±11.1 years, with no significant difference in gender distribution. PBP was controlled in 55 (59.8%), and CBP in 53 (57.6%). Both PBP and CBP were controlled in 50 patients (54.3%) and neither was controlled in 34 (37.9%). pPP and cPP were significantly lower in those with controlled PBP (p<0.001) and CBP (p<0.001). AI was non-significantly lower in those with controlled PBP (78±9 vs. 80.7) and those with controlled CBP (78±9 vs.81±7) (p=0.02). SEVR was within the desirable range in 92 patients (92.2%). 78.4% of individuals were taking drugs acting on the renin angiotensin aldosterone system (RAAS). CONCLUSIONS: In a convenience sample of 92 patients, PBP and CBP were controlled in 59.8% and 57.6%, respectively. Those with controlled PBP had significantly better peripheral systolic and diastolic blood pressure, CBP, pPP and cPP; the same was true of those with controlled CBP, who also had a significantly better AI. The percentage of the cardiac cycle in diastole had a desirable value for 92,2% of the subjects.

[Patient's relationship with the medical prescription - an observational study in urban populations in the ambulatory setting of General Practice/Family Medicine in the centre of Portugal]. / A relação dos doentes com a receita médica - um estudo observacional em populações urbanas no centro de Portugal.

INTRODUCTION: The vast majority of General Practice/Family Medicine appointments end with a pharmacological prescription. It is therefore important to study the expectations facing the reasons to treat and the value attributed to the prescribed medicines, by patients. OBJECTIVES: To know the expectations of patients facing the decision to treat and the therapeutic value attributed to prescribed medicines, by gender, academic grading, profession and age groups. MATERIAL AND METHODS: In an observational study using a validated questionnaire, a non probabilistic convenience population representing, by gender and age groups, the universe of the urban attendants of a Primary Care facility in central Portugal, was studied. The questionnaire was applied, after informed consent, in an interview with a psychologist, for anonymous self-fulfillment. Descriptive and inferential statistics were performed. RESULTS: A population of 180 individuals was studied, mean age 47,3 ± 17,0 years (ns by gender) median 45 years, mode 29, being 85 males (47,2%). No differences were found by gender, profession and age groups. There is a clear preference for the treatment of the diseases the doctor has diagnosed. A frequency of 2,8% would prefer to define the medical prescription. Patients think that prescribed medicines aim to increase health (79,5%) and to treat the diagnosed diseases (67,6%). Older and non actives agree that prescribed medicines are targeted to the problems they presented, while younger ones medicines are targeted for their diseases. For the active ones prescribed medicines are to improve health. DISCUSSION: Patient's expectations about the decision of treating are technically oriented and medicines are thought of as a tool for healing and also as a mean to increase health. These two perspectives urge general practitioners/family doctors to make good patients medicines information and to define therapeutical objectives with patients. CONCLUSIONS: The knowledge of the patients' expectation on pharmacological therapy can help increase its results, once patients wish to be treated of the diseases doctors diagnose and think that medicines cure diseases and increase health.

Ankle-brachial index according to pulse pressure and microalbuminuria in hypertensive patients: a prospective study in family medicine.

INTRODUCTION: Microalbuminuria, as determined by the urinary albumin to creatinine (AC) ratio, is a marker of target organ damage (TOD) in hypertensive patients. Pulse pressure (PP) predicts arterial elasticity and the ankle-brachial index (ABI) is a marker of cardiovascular morbidity. TOD reduction should be achieved through improvements in these indices. OBJECTIVE: To determine whether ABI, calculated as the ratio between mean PP in the upper and lower limbs, is associated with a reduction in renal damage, as measured by the AC ratio. METHODS: This was a prospective interventional study based on an intention-to-treat analysis in an opportunity sample of patients treated by three specialists in family medicine, with three-monthly follow-up over a total of six months. Blood pressure was measured in arms and ankles, and PP was calculated and used to determine right and left ABI and mean overall ABI. The AC ratio was determined by urine dipstick test. Descriptive and inferential statistical analysis was performed. RESULTS: A sample of 75 patients were studied (42.4% women), of whom(42.4% women), of whom 27.6% were diabetic, 46.7% overweight/obese and 49.3% dyslipidemic. overweight/obese and 49 dyslipidemic. There were statistical differences for right ABI (as determined by PP) and for mean overall ABI (as determined by mean PP in lower and upper limbs). Bivariate correlation analysis showed that in the group with improved PP between the first and the third observations, n=23 (40%), there was a statistically significant reduction in AC ratio (r = -0.924, two-tailed p < 0.001); the opposite was observed in the group with reduced PP, in which the AC ratio increased. DISCUSSION: ABI determined by systolic blood pressure is an excellent predictor of hemodynamic alterations. Increased ABI, based on PP, was accompanied by improved urinary AC ratio. These results are in line with the international literature. CONCLUSIONS: An improvement in urinary AC ratio--a predictor of TOD--is observed when an improvement in the ankle PP/brachial PP ratio is achieved.

[Non steroidal anti-inflammatory drugs prescription in General Practice in the centre of Portugal from 2007 to 2009]. / Prescrição de anti-inflamatórios não esteróides em medicina geral e familiar no centro de Portugal entre 2007 e 2009.

BACKGROUND: Non steroidal anti-inflammatory drugs computer-assisted prescription in General Practice/Family Medicine (GP/FM) ambience can give information about the prescription profile during a period of time and understand its trend. Such prescription profile could vary according to the urban (city) vs non urban (village) setting of the GP/FM practice. OBJECTIVES: To characterize the prescription trends of non steroidal inflammatory drugs (NSAIDs) in General Practice, from 2007 to 2009, by public sales price per inscript, daily defined doses (DDD) per inscript and price of DDD. To verify differences of the three fractions according to the urban vs non urban health centre. MATERIAL AND METHODS: Retrospective observational study conducted in February 2010, by the analysis of prescription informatic files automatically generated when the prescription was made. Population calculated at the middle point of each period of study. The differences in volume prescription in Daily Defined Dose (DDD) per registered patient in the middle of 2006 and 2007 two semesters, as well as the value of prescription measured by the price per registered patient were calculated and medicines were studied by the third level of the Portuguese medicines classification very similar to the ATC. The price per DDD was calculated as well. RESULTS: The studied population was of 315.377 subjects in 2007, 321.784 in 2008 and 331.106 in 2009. In price per inscript urban health centres showed a growth from 2007 to 2009 in "Indol and Inden" derivatives (+51.6%), in "Propionic acid derivatives" (+39.4%) and in "Selective cox-2 inhibitors" (+33.6%). For "Sulfanilamidic derivatives, a reduction of 3.8% was verified. For non urban Health Centres prescription a generalised reduction in price per inscript was observed. For DDD/per inscript from 2007 to 2009 we found a generalised increase for urban health centres, except for "Oxicans". For non urban Health Centres there is a generalised decrease of DDD/per inscript from 2007 to 2009, with a special decrease for non-acidic compounds. As for Price of DDD from 2007 to 2009 there is a generalised reduction of such ratio with the only exception of "non acidic compounds" (+9,1%) for urban Health Centres. In view of the calculated ratios, the differences by urban vs non urban Health Centre in each of the studied years there is a significant higher value in non urban health centre, with the exception of Price of DDD for 2008 and 2009 where such ratio is non significantly higher in urban heath centre. CONCLUSIONS: During the study period, demographic growth was higher than the prescription growth in volume and in value. Prescription was more frequent and expensive in non-urban Health Centres. Price of DDD decreases from 2007 to 2009 signifying a much cheaper NSAIDs therapeutics.

[Medicines, anxiety and depression]. / O medicamento, a ansiedade e a depressão.

OBJECTIVE: To ascertain the opinion about anxiety, depression and the medicines to treat them by gender, labour activity and age. MATERIAL AND METHODS: validated questionnaire; patients attending a Central Portugal Health Centre; doctors and nurses that proposed the questionnaire to all attending patients. Cross sectional observational study, by anonymous and secret self-fulfilment, in a convenience sample drawn from a population composed by all those attending the Health Centre between the 22nd June and the 3rd July (both inclusive) 2009. Descriptive and inferential statistics were performed by means of a SPSS 11.0 statistical package. Age groups were defined as: < 36 years, 36-55 years, =56 years and professional activity groups as non-actives (students, retired and unemployed) and actives (housewives, and workers in primary, secondary and tertiary sectors). RESULTS: A n = 281 sample was studied age distribution of < 36 years = 47,7%, 36-55 years = 36,7% and = 56 years = 15,6%, mostly active (69,4% actives) and predominantly female (71,6% women). Age distribution is normal (Kolmogorov-Smirnov Z = 1,644 2 tailed p = 0,009). As results of agreement vs disagreement, showing the significant differences, 'In general medicines for anxiety and for depression are capable of making me feel well' (71,4% vs 15,2%, p = 0,035 by age group), 'In general medicines can relieve the unpleasant sensations caused by day by day stress of actual society' (67,7% vs 22,6%, ns), 'If necessary medicines can relieve my anxiety or depression problems' (52,0% vs 34,1%, p = 0,000 by gender) and 'Anxiety and depression problems are displays of body illnesses' (42,8% vs 33,2%, ns). There is a majority of disagreement for 'In general medicines can, by themselves cure depression or anxiety' (72,5% vs 20,7%, p = 0,013 by sex), 'In general medicines for anxiety or depression can help change the way one sees the problems' (49,4% vs 43,4%, p = 0,041 by age group, p = 0,004 by sex, p = 0,002 by group of professional activity), 'I can feel good just by taking medicines' (71,4% vs 19,8%, p =0,008 by sex, p = 0,006 by professional activity group) and 'Medicines can bring more joy to my life' (58,5% vs 23,9%, p = 0,008 by sex, p = 0,006 by professional activity group). Anxiety problems and depression problems are demonstrations of body diseases, 42,8% vs 33,2%, ns). CONCLUSIONS: The pharmacological treatment for anxiety or depression must be individualised by sex, gender, age and activity of patients. In general medicines are judged capable of curing anxiety and depression problems but in the particular own case their activity is considered. Anxiety problems and depression problems are considered as manifestations of the body's disease.

[Non-steroidal anti-inflammatory drugs prescription in General Practice setting: 435 does informatics have any influence?]. / Prescrição de anti-inflamatórios não esteróides no ambiente de Medicina Geral e Familiar: a informática influencia?

AIMS: In the ambulatory setting of General Practice/Family Medicine, a retrospective, observational study was carried out to ascertain variation on non-steroidal anti-inflammatory drugs prescription, in an informatics environment where name (brand or chemical), size of package, price and the existence of generic medicines is available. METHODS: Observational transversal study conducted in February 2008 with no prescription study warning given to the doctors in the study period. The differences in volume prescription in Daily Defined Dose (DDD) per registered patient in the middle of 2006 and 2007 two semesters, as well as the value of prescription measured by the price per registered patient were calculated and medicines were studied by the third level of the Portuguese medicines classification very similar to the ATC. The price per DDD was calculated as well. RESULTS: DDD volume and value declined throughout the study comparing entire years or semesters being "Oxicans" the only exception. Even though, the net volume and value decreased between 2006 and 2007 comparing both semesters of 2006 and of 2007. Price per DDD decreased for all medicines except for oxicans with an increase from the first to the second semesters of 2007. CONCLUSIONS: Informatics environment influences the prescription of non-steroidal anti-inflammatory drugs, reducing the number of DDD and the price per registered patient.