Tijuca forest contribution to the improvement of air quality and wellbeing of citizens in the city of Rio de Janeiro, Brazil.

The Tijuca Forest, one of the largest urban forests in the world, is a protected area of the Brazilian Atlantic Forest, one of the world's biodiversity hotspots. The forest and the Metropolitan Region of Rio de Janeiro coexist and interact, but their mutual influence regarding air quality is still not well known and a more detailed study is needed. Here, air samples were collected inside the forest, in Tijuca National Park (TNP) and Grajaú State Park (GSP) and in two representative urban areas (Tijuca and Del Castilho Districts). Sampling was performed using stainless steel canisters, and ozone precursor hydrocarbons (HCs) were analyzed with the aid of heart-cutting multidimensional gas chromatography. The sampling points within the forest are currently visited by hundreds of people. Total HC concentrations within the green area were clearly lower than in the urbanized districts, in spite of the anthropogenic impact of visitors and the proximity of the urban area. Median values were 21.5, 35.5, 57.9 and 148.6 µg m-3 at TNP, GSP, Tijuca and Del Castilho, respectively. Total HC concentrations were Del Castilho > Tijuca > GSP > TNP. The kinetic reactivity and ozone-forming potential of individual HCs were evaluated, as well as the intrinsic reactivity of air masses. The air masses in the urbanized area showed a higher average reactivity in all scales. In fact, in spite of the forest's contribution to isoprene emissions, its net contribution to ozone formation was lower than that of urbanized air masses, owing to a reduction in HC concentration, particularly for alkenes and monoaromatic compounds. It is not clear if the forest plays a role in the adsorption of pollutants or if it acts as a physical natural barrier to air masses carrying pollutants. Nonetheless, improving air quality within Tijuca Forest is essential to the welfare of citizens.

Analysis of physiological markers and risk factors for the development of rhabdomyolysis in military personnel: a systematic review.

OBJECTIVES: To analyze case reports with individual patient data belonging to the Armed Forces submitted to specific physical or military combat training that was affected by rhabdomyolysis and identify factors that influenced the diagnosis and clinical evolution of the syndrome. CONTENT: We conducted a systematic review following the PRISMA guidelines and registered on PROSPERO (CRD42021242465). We searched MedLine (via PubMed), Scopus, Cochrane, Lilacs, SciELO, CINAHL, Web of Science, SPORTDiscus, ScienceDirect, and PEDro databases for studies that reported cases of military personnel affected by rhabdomyolysis. SUMMARY AND OUTLOOK: Thirteen studies met the inclusion criteria. Forty-nine individual cases of rhabdomyolysis were analyzed. From them, it was possible to identify several associated factors, which were responsible for developing rhabdomyolysis in military personnel. Thirty military personnel (60%) practiced physical training and 20 (40%) practiced specific military combat training. The creatine kinase (CK) peak ranged from 1,040 to 410,755 U/L, with an average of 44.991 U/L, and 14 (28%) of the cases reported alteration of renal function and four militaries (8%) evolved to death condition. Physical activities performed strenuously and without proper planning conditions such as room temperature, the period without adequate water intake, the amount of equipment used during the activity contributed to the development of rhabdomyolysis in the cases of military personnel analyzed in the present study. Therefore, it is recommended that future studies investigate the relationship between the prevalence of rhabdomyolysis cases and the severity of its consequence when associated with progressive methods of training, hydration control, acclimatization to austere environments, monitoring for the existence of hereditary diseases, and control of the use of supplementary nutritional substances.

Construção de ferramentas para padronização da classificação de risco em Unidade de Urgência de Sergipe / Construction of tools to standardize risk classification in the Emergency Unit of Sergipe

Introdução:as Unidades de Urgência 24 horas utilizam o acolhimento com classificação de risco para atender efetivamente os quadros clínicos ou agudizados. Contudo, alta demanda e falta de sistematização para a realização desse processo dificultam a identificação dos pacientes graves e agilidade no fluxo de atendimento ao aumentar o tempo de espera no atendimento dos usuários. descrever a construção e implementação do Objetivo:protocolo operacional padrão (POP) melhorar o fluxo de atendimento na Unidade de Urgência 24 horas em um município sergipano. Métodos:trata-se de um estudo descritivo, do tipo relato de experiência sobre o processo de construção de um POPpara a classificação de risco e de ferramentas para implementação na unidade, realizado entre novembro de 2022 e fevereiro de 2023. As fundamentações teóricas para construção do protocolo seguiram as diretrizes do Ministério da Saúde sobre acolhimento com classificação de risco e instrumentos adotados em outras unidades de urgência. Conclusões:o uso de ferramentas assistenciais padronizadas é essencial para a resolutividade da superlotação e fluxo de comunicação nas unidades de urgência. Assim, o estudo identificou a necessidade da padronização da classificação de risco, bem como a sua importância para a sensibilização da população.

Rhabdomyolysis Episode in an Individual with McArdle's Disease after Low Aerobic Exercise.

McArdle's disease, known as blockage of muscle glycogen metabolism, is characterized by glycogen accumulation of chains in skeletal striated muscles. One of the typical symptoms of the disease is the feeling of intolerance to exercise. Severe muscle cram and contracture, which often cause stiffness, occur due to a lack of muscle energy substrate during the exercise. These factors can lead to muscle damage, myoglobinuria, and, in severe cases, renal failure and rhabdomyolysis. Rhabdomyolysis is a syndrome that presents injury and necrosis of muscle cells leading to the release of intracellular material to the circulatory system. The present study aimed to report rhabdomyolysis in an individual with McArdle's disease after exercise of walking with low intensity. Patient, aged 33 years, was treated in the emergency room of a hospital located in the State of Rio de Janeiro, Brazil. After performing a full lap on the block of home (~500 m in ~4 min 37 s), walking at a moderate speed (~6.5 km/h), the individual felt sick and was rescued, later being hospitalized. The examinations collected presented hematocrit (HCT) compatible with chronic disease anemia and myoglobinuria. The patient was discharged from the intensive care center on the 3rd day, after a 45% drop in creatine kinase. The patient described in the present study achieved full recovery. Attention to symptoms, early diagnosis, and immediate treatment made it possible to interrupt the development of complications caused by rhabdomyolysis, not allowing progression to acute renal failure.

Benzene, Toluene, Ethylbenzene and Xylene (BTEX) Concentrations in Urban Areas Impacted by Chemical and Petrochemical Industrial Emissions.

The Metropolitan Region of Rio de Janeiro is the second largest urban and industrial region in Brazil. While the south and south-east areas are affected by vehicular emissions, the districts and cities located in the northern area are subjected to industrial emissions and have the poorest air quality of the region. In this study, BTEX concentrations were determined in the District of Irajá, a residential area located in the north of the city of Rio de Janeiro, approximately 25 km from the industrial zone, as well as in the District of Jardim Primavera, in the city of Duque de Caxias. The mean values for total BTEX concentrations were 38.4 ± 11.7 and 44.6 ± 29.3 µg m-3, in Irajá and Jardim Primavera, respectively, which are higher than those previously reported for other areas. The benzene/toluene rates, (approximately 0.5 for both sampling sites), were also higher than typical values that were determined for diesel and gasoline emissions through dynamometer experiments.

Desafios na comunicação entre homens e seus médicos de família / Communication challenges between men and family doctors / Desafíos en la comunicación entre hombres y sus médicos de familia

O artigo discute aspectos da comunicação na relação médico(a) + homem usuário no contexto de serviços com Estratégia de Saúde da Família (ESF). A presente pesquisa qualitativa foi realizada em três fases distintas e articuladas, com triangulação de técnicas (entrevistas semiestruturadas e grupos focais) e com homens usuários e médico(a)s de Família e Comunidade (MFC) em serviços de saúde em Florianópolis, SC, Brasil. As análises apontam que a busca por consulta é guiada por sintomas e/ou pressão de familiares e pela expectativa por exames que comprovem estarem saudáveis. O(a)s MFC incentivam o autocuidado sem efetivamente convencer os usuários. A troca frequente de médico(a) é um forte entrave para o vínculo e a comunicação. O estudo contribui para o debate sobre a relação médico(a) + pessoa em segmento da população reticente e pouco envolvido com o autocuidado e a prevenção. (AU)

This article discusses aspects of communication in the doctor-male patient relationship in the context of family health strategy services. A qualitative study was undertaken with family and community doctors (FCDs) in health services in Florianópolis, Brazil in three distinct stages using triangulation techniques (semi-structured interviews and focus groups). The findings show that seeking an appointment was guided by symptoms and/or family pressure and the expectation of receiving examination results that show that the patient is healthy. The FCDs encouraged self-care without effectively convincing the patients. The frequent change of doctors strongly hampered the creation of doctor-patient bonds and communication. This study contributes to the discussion about doctor-patient relationships in a segment of the population that is reticent and not very engaged in self-care and prevention. (AU)

El artículo discute aspectos de comunicación en la relación médico(a) + hombre usuario en el contexto de servicios con Estrategia de Salud de la Familia (ESF). Investigación cualitativa realizada en tres fases distintas y articuladas, con triangulación de técnicas (entrevistas semiestructuradas y grupos focales), con hombre usuarios y Médicos(as) de Familia y Comunidad (MFC) en servicios de salud en Florianópolis, Estado de Santa Catarina, Brasil. Los análisis señalan que la búsqueda de la consulta es dirigida por síntomas y/o presión de familiares y por la expectativa de realización de análisis que demuestren que están saludables. Los(las) MFCs incentivan el autocuidado, sin efectivamente convencer a los usuarios. El cambio frecuente de médico(a) es un fuerte obstáculo para el vínculo y la comunicación. El estudio contribuyó para el debate sobre la relación médico(a)+persona en un segmento de la población reticente y poco involucrado en el autocuidado y la prevención. (AU)

Increased ozone levels during the COVID-19 lockdown: Analysis for the city of Rio de Janeiro, Brazil.

The first COVID-19 case in Brazil was confirmed on February 25, 2020. Partial lockdown measures came into force in the city of Rio de Janeiro, Brazil, on March 23. While CO and NO2 levels showed significant reductions, PM10 levels were only reduced in the first partial lockdown week. By contrast, ozone levels increased in all studied locations. In this study, the factors leading to this behavior were analyzed. Monitoring data obtained at two automatic monitoring stations showed higher ratios between non-methane hydrocarbons and nitrogen oxides (NMHC/NOx) during the partial lockdown (up to 37.3%). The increase in ozone concentrations during the social distancing measures could be attributed to the increase in NMHC/NOx ratios since atmospheric chemistry in Rio de Janeiro is under VOC-controlled conditions. However, the increase was higher when air masses arrived from the industrial areas, not only because of the higher NMHC/NOx ratios, but also because the reactivity of VOC was highly increased by these air masses, which are rich in aromatic compounds.

The impact of COVID-19 partial lockdown on the air quality of the city of Rio de Janeiro, Brazil.

The first COVID-19 case in Brazil was confirmed on February 25, 2020. On March 16, the state's governor declared public health emergency in the city of Rio de Janeiro and partial lockdown measures came into force a week later. The main goal of this work is to discuss the impact of the measures on the air quality of the city by comparing the particulate matter, carbon monoxide, nitrogen dioxide and ozone concentrations determined during the partial lockdown with values obtained in the same period of 2019 and also with the weeks prior to the virus outbreak. Concentrations varied with substantial differences among pollutants and also among the three studied monitoring stations. CO levels showed the most significant reductions (30.3-48.5%) since they were related to light-duty vehicular emissions. NO2 also showed reductions while PM10 levels were only reduced in the first lockdown week. In April, an increase in vehicular flux and movement of people was observed mainly as a consequence of the lack of consensus about the importance and need of social distancing and lockdown. Ozone concentrations increased probably due to the decrease in nitrogen oxides level. When comparing with the same period of 2019, NO2 and CO median values were 24.1-32.9 and 37.0-43.6% lower. Meteorological interferences, mainly the transport of pollutants from the industrial areas might have also impacted the results.

Impact of the Petrochemical Complex on the Air Quality of an Urban Area in the City of Rio de Janeiro, Brazil.

In the city of Rio de Janeiro (Brazil), the districts located in the northern area are considered the most critical regarding ozone levels year-round. In this study, the potential factors that contribute to high levels of ozone in the district of Irajá were investigated. The obtained results clearly showed that, in spite of the high correlation of ozone concentrations with wind speed and temperature, ozone episodes depend on the ratios of volatile organic compounds (VOCs) to nitrogen oxides (NOx) rather than on the individual VOC and NOx levels, as expected for the VOC-controlled condition typical of the urban area of Rio de Janeiro. Moreover, high VOCs/NOx ratios are highly dependent on the transport of air masses. When pollutants are transported from urban areas with heavy vehicular flux and high NOx concentrations, ozone levels are reduced. When air masses are transported from the industrial petrochemical area, NOx levels are relatively low, and ozone episodes are frequent.

Levels of Volatile Carbonyl Compounds in the Atlantic Rainforest, in the City of Rio de Janeiro.

When Europeans arrived in America, the Brazilian Atlantic rainforest covered approximately 1,290,000 km2. Now, only 8% of the biome's original vegetation remains. One of the largest areas is Tijuca Forest National Park. In this work, the concentrations of 13 carbonyl compounds in an isolated area inside Tijuca Forest, in an urban park with primary and secondary vegetation (Gericinó Natural Park) and in two typical urban areas (Tijuca District and the city of Nilópolis) were determined. The main compounds were formaldehyde and acetaldehyde. The formaldehyde mean concentrations were 0.98 ± 1.00, 1.27 ± 1.67, 3.09 ± 1.60 and 2.33 ± 2.17 µg m-3 for Tijuca Forest, Gericinó Natural Park, Tijuca District and the city of Nilópolis, respectively. The mean acetaldehyde concentrations were, for the same locations, 0.93 ± 1.05, 2.94 ± 2.54, 2.78 ± 0.91 and 5.48 ± 1.90 µg m-3. The results indicate that the compounds measured within the forest are transported from the city and that the trees play an important role in removing air pollutants. In contrast, the Gericinó protected area is heavily affected by urban emissions, and its capacity to dilute or absorb pollutants is low because of the sparse vegetation.

Subjetividades de homens rurais com problemas cardiovasculares: cuidado, ameaças e afirmações da masculinidade / Subjectivities of rural men with cardiovascular problems: care, threats, and masculinity affirmations

Resumo O artigo discute subjetividades cotidianas que podem fragilizar ou (re)afirmar a masculinidade e, por conseguinte, afastar os homens rurais do cuidado para com a saúde. Com abordagem qualitativa, a pesquisa foi aplicada em uma comunidade rural de município localizado no sul do Rio Grande do Sul com a participação de doze homens que vivenciaram adoecimento cardiovascular crônico. Os achados ilustram diferentes ações eleitas pelos entrevistados como ameaçadoras à masculinidade e que, portanto, devem ser evitadas ou negadas, redirecionando-se para um movimento de afirmação dos estereótipos de gênero. Evidenciou-se nas análises que determinadas prescrições associadas à masculinidade - como a crença na invulnerabilidade, o papel de provedor e a associação do cuidado com a feminilidade - podem acarretar prejuízos à saúde física, mental e social dos homens, em especial no envelhecimento, quando as fronteiras entre o que se deseja e o que se consegue atender se acentuam. Com o olhar para o rural, o estudo fornece aportes para pensar ações no campo da promoção da saúde masculina em sua pluralidade de contextos de vida, trazendo para a discussão o cenário de vida camponês e suas especificidades produtivas, que conformam e moldam situações de saúde.

Abstract The article discusses daily subjectivities that may undermine or (re)affirm masculinity and thus alienate rural men from taking care of their health. Through a qualitative approach, the research was conducted within a rural community in a municipality in the south of Rio Grande do Sul (Brazil) and involved twelve male participants who experienced chronic heart disease. The findings illustrate different actions which were elected by the respondents as threats to their masculinity and that, therefore, should be avoided or denied, leading to an affirmation of gender stereotypes. The analyses made clear that certain prescriptions associated with masculinity, such as the belief in invulnerability, the role of the provider and the link between self care and femininity, may cause physical, mental, and social harm to men, especially during old age, when the boundaries between goals and possibilities become further apart. Focusing on the rural aspect, the study provides ideas for the development of actions towards men's health promotion, taking into consideration their life context plurality and bringing the farmer's life sphere and all its productive particularities, which shape health scenarios, to the discussion.

Transexualidade e cárcere: o direito à terapia hormonal das pessoas transexuais em unidades prisionais

Ao serem condenadas ao cumprimento de pena privativa de liberdade em unidades prisionais, as pessoas transexuais são encaminhadas ao presídio que corresponde ao seu sexo biológico e identidade civil. Dessa forma, a problemática se instala quando, ao encarcerar a pessoa trans que esteja passando por tratamento de terapia hormonal por acompanhamento médico, este lhe seja negado durante o cumprimento da pena, interrompendo, assim, o processo de redesignação de gênero. O objetivo do presente trabalho é analisar, sob a luz da Constituição Federal, da Lei de Execução Penal, da Declaração Universal dos Direitos Humanos bem como os Princípios de Yogyakarta, ligando-os à Resolução Conjunta nº1/2014, do Conselho Nacional de Combate à Discriminação, a proteção do direito da pessoa transexual em ter o seu tratamento hormonal continuado ainda que encarcerada, a fim de não comprometer a sua expressão de gênero, bem como a sua saúde no âmbito das unidades prisionais. Para tanto, utiliza-se da pesquisa bibliográfica e o método empírico analítico para o desenvolvimento do estudo, observando que a ausência de legislação voltada para a população transexual encarcerada não pode obstar o exercício de sua cidadania, ainda que privada de liberdade

Contextual factors in clinical decision making: national survey of Canadian family physicians.

OBJECTIVE: Many factors are at play in the process of clinical decision making, but to date, the interaction of these factors has not been well understood. Such information could have important implications for teaching and promoting evidence-based medicine (EBM) in primary care. This study was designed to explore the relationship between physician-related variables and management of patient-related contextual factors in clinical decision making. A secondary objective was to examine the extent to which this relationship varies by type of clinical decision. DESIGN: Cross-sectional randomized postal survey of 1134 Canadian primary care physicians stratified by age, sex, and practice location. Nonrespondents were sent reminders at 4 weeks and again at 8 weeks; at 12 weeks, all remaining nonrespondents were mailed replacement copies of the questionnaire. SETTING: Family practices in Canada. PARTICIPANTS: Of the final sample of 431 family physicians, 52% were men, 63% practised in urban locations, and 71% were in group practice. MAIN OUTCOME MEASURES: Self-reported likelihood of considering various contextual factors during the course of clinical decision making. RESULTS: Despite the three follow-up mailings, the final response rate was 42%; however, nonrespondents did not differ significantly from respondents on three important demographic factors: age, sex, and practice location. Using multinomial logistic regression analysis, the data showed that female family physicians and practitioners less strongly identified with EBM were more likely to consider contextual factors in clinical decision making. The effect was more obvious for ordering tests than for decisions about treatment. CONCLUSION: The evolving model of EBM should consider important physician-related variables in clinical decision making. Our data indicate that physicians' sex and identification with the tenets of EBM influence management of contextual factors. These results have important implications because they indicate that clinicians strongly identified with the EBM model of clinical practice are less sensitive to context, which might be an obstacle to efforts to integrate patient values and clinical circumstances into patient-centred care. We believe these findings support continued development of the model of "context-sensitive medicine" previously proposed as an alternative to EBM.

Feasibility of a patient decision aid regarding disclosure of personal health information: qualitative evaluation of the Health Care Information Directive.

BACKGROUND: Concerns regarding the privacy of health information are escalating owing both to the growing use of information technology to store and exchange data and to the increasing demand on the part of patients to control the use of their medical records. The objective of this study was to evaluate the Health Care Information Directive (HCID), a recently-developed patient decision aid that aims to delineate the level of health information an individual is willing to share. METHODS: We convened a series of four focus group meetings with several communities in a large Canadian city. A total of 28 men and women participated, representing health care consumer advocates, urban professionals, senior citizens, and immigrants who speak English as a second language. Data were analysed using qualitative methods. RESULTS: Participants lacked substantial knowledge regarding the fate and uses of personal health information. They expressed mistrust concerning how their information will be used and protected. Several suggestions were made towards customizing the use of data according to specific needs rather than broad and full access to their charts. Furthermore, despite concern regarding the implementation of a tool like the HCID, participants were hopeful that a refined instrument could contribute to the improved regulation of health information. CONCLUSION: This study indicated poor knowledge concerning the uses of personal health information, distrust concerning security provisions, and cautious support for a patient decision aid such as the HCID to improve control over health data.

Patients' perspectives on taking warfarin: qualitative study in family practice.

BACKGROUND: Despite the well-documented benefits of using warfarin to prevent stroke, physicians remain reluctant to initiate therapy, and especially so with the elderly owing to the higher risk of hemorrhage. Prior research suggests that patients are more accepting of the risk of bleeding than are physicians, although there have been few qualitative studies. The aim of this study was to employ qualitative methods to investigate the experience and perspective of individuals taking warfarin. METHODS: We conducted face-to-face interviews with 21 older patients (12 male, 9 female) who had been taking warfarin for a minimum of six months. Participants were patients at a family practice clinic situated in a large, tertiary care teaching hospital. We used a semistructured interview guide with four main thematic areas: decision-making, knowledge/education, impact, and satisfaction. Data were analysed according to the principles of content analysis. RESULTS AND DISCUSSION: Participants tended to have minimal input into the decision to initiate warfarin therapy, instead relying in great part on physicians' expertise. There appeared to be low retention of information received regarding the therapy; half the patients in our sample possessed only a superficial level of understanding of the risks and benefits. This notwithstanding, participants reported a high level of satisfaction with the care provided and a low level of impact on their day-to-day lives. CONCLUSIONS: Minimal patient involvement in the initial decision and modest knowledge did not appear to diminish satisfaction with warfarin management. At the same time, care providers exert a tremendous influence on the initiation of warfarin therapy and should strive to incorporate patient preferences and expectations into the decision-making process.

The nexus of evidence, context, and patient preferences in primary care: postal survey of Canadian family physicians.

BACKGROUND: Evidence-based medicine is gaining prominence in primary care. This study sought to examine the relationships among family physicians' attitudes toward EBM, contextual factors, and clinical decision-making and to investigate the factors that contribute to 'contrary to evidence' clinical decisions. METHODS: A postal survey mailed to a random sample of Canadian family physicians, stratified by age, gender, and practice setting. The main outcome measures were respondents' attitudes toward evidence-based medicine and preferred treatment option in four simulated clinical scenarios with wording randomly varied. RESULTS: Canadian family physicians report positive attitudes toward EBM, believe that EBM improves patient care, and agree that research findings are useful in the day-to-day management of patients. The scenario study showed that physicians were strongly influenced by a patient demanding/requesting either a screening test (adjusted Odds Ratio [OR] 5.15, 95% confidence interval [CI] 2.9 to 9.2 for demand mammogram; adjusted OR 3.11, 95% CI 1.7 to 5.6 for request mammogram) or a diagnostic test (adjusted OR 3.95, 95% CI 2.1 to 7.5 for demand lumbar spine x-ray; adjusted OR 2.08, 95% CI 1.1 to 4.1 for request x-ray). This relationship did not hold for the treatment scenario (prescribing antibiotics for acute bronchitis) where hours of practice (adjusted OR 3.5, 95% CI 1.1 to 11.7 for 50+ hours practice; adjusted OR 1.79, 95% CI 1.0 to 3.2 for 20-49 hours practice) and type of practice (adjusted OR 2.22, 95% CI 1.3 to 3.7 for solo practice) were significant. 80% of respondents reported teaching breast self-examination with female physicians twice as likely as males (adjusted OR 2.11, 95% CI 1.2 to 3.8). CONCLUSIONS: Canadian family physicians are favourably disposed to the precepts of evidence-based medicine; however, patient expectations and practice characteristics can influence physicians such that decisions are taken that are broadly contrary to evidence. Recently revised models of EBM emphasizing the importance of patient preferences and the clinical context appear to reflect more accurately the clinical reality of primary care physicians.

Evidence-based medicine in primary care: qualitative study of family physicians.

BACKGROUND: The objectives of this study were: a) to examine physician attitudes to and experience of the practice of evidence-based medicine (EBM) in primary care; b) to investigate the influence of patient preferences on clinical decision-making; and c) to explore the role of intuition in family practice. METHOD: Qualitative analysis of semi-structured interviews of 15 family physicians purposively selected from respondents to a national survey on EBM mailed to a random sample of Canadian family physicians. RESULTS: Participants mainly welcomed the promotion of EBM in the primary care setting. A significant number of barriers and limitations to the implementation of EBM were identified. EBM is perceived by some physicians as a devaluation of the 'art of medicine' and a threat to their professional/clinical autonomy. Issues regarding the trustworthiness and credibility of evidence were of great concern, especially with respect to the influence of the pharmaceutical industry. Attempts to become more evidence-based often result in the experience of conflicts. Patient factors exert a powerful influence on clinical decision-making and can serve as trumps to research evidence. A widespread belief that intuition plays a vital role in primary care reinforced views that research evidence must be considered alongside other factors such as patient preferences and the clinical judgement and experience of the physician. DISCUSSION: Primary care physicians are increasingly keen to consider research evidence in clinical decision-making, but there are significant concerns about the current model of EBM. Our findings support the proposed revisions to EBM wherein greater emphasis is placed on clinical expertise and patient preferences, both of which remain powerful influences on physician behaviour.