The emotional impact of medical error on Portuguese medical residents - An exploratory study

Background

The consequences of the medical error on patients are unquestionable. However, the emotional impact on the health professional that made the error is usually devastating and usually neglected. The present study aimed to study the perception and experiences in a sample of medical residents regarding the emotional impact of the medical error in a clinician.

Methods

A cross-sectional and exploratory study analyzed a sample of 264 Portuguese residents. A survey with multiple-choice questions was created, taking into account the available scientific literature on this topic. The survey was then shared online within the mailing lists and social groups of Portuguese medical residents. The responses were collected between 14th-29th February 2020. Descriptive and logistic regression analyses were carried out using R 3.6.1 and Rstudio 1.2.5033.

Results

48,1% of the residents mentioned that at a certain point in their careers, they made a medical error. 98,4% of them had indirect contact (e.g., discussions with colleagues) with scenarios where a medical error could or was made. The residents that made a medical error had mainly feelings of guilt (85,8%), anxiety (73,2%), and frustration (64.6%). 93,7% of the clinicians that made a medical error reported more caution and the implementation of preventive measures in their future practice. 16,5% of them thought about leaving the medical profession. The odds for a medical error are 2,44 higher (95% CI 1,49-4,02) in the later phase of medical residency.

Conclusions

Although international literature describes the impact of medical error on the clinician, there is no published research on this theme in Portugal. The results allowed us to explore the emotional impact of these events and underline the unmet need for psychological support for the health professional. This exploratory study may serve as support for other research studies on this matter with a more robust methodology and a bigger sample size.

Key messages

Medical error is frequent and has an emotional impact on medical residents. Need for further research in Portugal and the creation of programs for psychological support.

Knowledge at palm of hand: supported self-management and audiovisual content School of Patients DF

Background

The region of practice of the School of Patients DF is vulnerable at health literacy and income. Audiovisual information is strategic in primary care for its great power of reach and information retention.

Objectives

Since 2016 videos of health education have been produced, initially technical on the Planification for hypertension and diabetes. After the focus switched to popular health education, aiming at improving communication between health professionals and patients on chronic diseases and health promotion, including testimonials. The is potential for video exhibition in qualified waiting rooms and forwarding in social network.

Results

There are videos from diabetes, hypertension, obesity to dengue, pre-natal care and other APS themes, which follow printed orientation with pertinent links. There are graduate and post-graduate studies in course for optimizing audio-visual content for support and capacitation of the family caregivers, especially regarding the facilitated visual model of prescription (“Illustrated Prescription”). Data until 2020-January: YOUTUBE 3146 views, 118,6 hours of exhibition, 50 videos. FACEBOOK page with a reach of 369.248 views. INSTAGRAM 10.119 followers, 193 posts, 37.800 likes and 1003 commentaries.

Conclusions

Modifications in lifestyle and adherence to medication are fundamental for treatment, and videos are promising for health promotion and selfcare capacitation. There is potential for reducing the hierarchy barriers (testimonials). The shared construction of knowledge and its dissemination makes the patient active part in community diffusion of information.

Key messages

Health professionals have a vital role as educators, including for social online networks. Patients have a protagonist role in their treatment, as well as multipliers of knowledge at their community.

Illustrated Prescription – History of evolution at the School of Patients DF

Issue

There are challenges in PHC associated with low functional literacy in health. The Illustrated Prescription was developed aiming to reduce drug error and increase access to self-care, allowing better understanding and adherence to treatment; facilitate the safe use of medications; strengthen the support network.

Description of the Problem

In April 2016, systematization and preparation of pictorial prescriptions began in the service of origin, one of the researches with the highest participation of multiprofessional residents of pharmacy and medical interns. Optimization and complement of recipe was performed. Several models were systematized in the orientation of users in face-to-face care of prescription reviews. The proposed model has (1) written component, schedule of medicines and strategy organizing medicines according to time of administration and (2) strategy for organizing primary packaging of medicinal products using coloured elastic bands.

Results

The evolution of Illustrated Prescription components resulted in the progressive organization and understanding in the indication of schedules and drugs. There was development, improvement and validation of it as a self-care tool, especially for patients with CNDs. There was a social impact with media dissemination (6 TV stations and 2 radio stations) and national and international congresses; totaling 5 show-forums and 4 congress with participation of the service. Cash prizes were invested in the infrastructure of the FHS workplaces.

Lessons

The evolution of Illustrated Prescription allowed progressive gain of organization and clarity for patients with difficulty reading, which directed efforts to avoid drug errors, especially prescription.

Key messages

Illustrated Prescription allowed us to invest more time guiding the patient in accessible and understandable language. Illustrated Prescription is useful for empowering and training it in self-care, promoting, mainly, autonomy and citizenship.

Each reading is a seed – prescribing books and links at the School of Patients DF

Issue

The fragile reading habit is a common feature in Brazil, having wide negative impacts in Health and Education areas. Itapoã-DF presents important social vulnerabilities with challenges about the reading habit. Stimulating individual reading from early childhood to elderly, associated with positive reinforcement during doctor appointments, is a way to provide health education.

Description of the problem

In October of 2016, the “Prescreva um Livro” (prescribe a book) project began from childcare doctor appointments, by encouraging children with books and the borrowing of material, in addition to positive reinforcement in consultations. In 2019, book references for adults were incorporated into the chapters of the School of Patients DF - especially for prenatal care and chronic conditions such as hypertension. It highlights the potencial of primary care as point of encouragement for reading and community support, reading coordinator.

Results

The Reading stimulus brought, since 2016, a change in the relationship of young people with the service, making it a space of curiosity and fun instead of “fear of needles”. The importance of primary care in constructive stimuli to reading is reinforced even more considering the difficulties of education in Brazil.

Lessons

Initially focused on children and adolescents, the practice was incorporated into the health education strategy of the School of Patients, grouping prevalent comorbidities and printed guidelines delivered at each consultation. The participating children reported the stories they had read at subsequent visits. This feedback reinforces the influence that the primary care environment can have in several areas of the user's life, including reading

Key messages

Waiting rooms and home visits are opportunities to exchange information also of a literary nature. The stimulus to reading is vital for the full exercise of citizenship, and health services can be a reference for reading.

Case simulations for permanent education in Primary Care – School of Patients DF

Background

In scenarios of vulnerability that include triple charge of diseases, permanent education in Primary Care and university is fundamental to allow greater access, efficiency and safety for users and health teams.

Objectives

The School of Patients DF was created as a tool for popular and technical health education, including case simulations for practice. It consists of standard technical content (Chapters), categorized by conditions and diseases, shared by Google Drive and used primarily in selected primary care units of Brazil's capital city.

Results

Technical simulations are performed in pairs, 1 participant acts as “patient” with script in hand (topics of the training) while the other acts as “health professional” as if in a regular visit. Simulations are timed for 10 minutes for consultation and 5 for feedback, boosting learning. Contents are based on guidelines and protocols from the Ministry of Health, Secretary of Health and Brazilian Community and Family Medicine Society. Since 2016 there have been realized over 1400 simulations, including weekly classes for last term medical students at the capital city federal university.

Conclusions

Simulations optimize the time necessary for permanent education (15 minutes blocks), avoiding limiting access for triage and consults, allowing smaller groups to train with greater focus and independent of computers or projectors.

Key messages

Standardizing training and practice bring benefit to patient care and safety. Simulations with structured physical examination are important both for professional as well as students.

Primary care professional validation of visual model of prescription – Illustrated prescription

Issue

Chronic diseases such as hypertension and diabetes have great global impact on morbidity, mortality and costs. Incorrect use of medicines is especially worrisome for vulnerable populations with low health literacy, and visual models of prescription can bring benefit. The objective of this study was to validate the visual model of prescription Illustrated Prescription to obtain an adapted prescription with greater clarity, correction and cost-efficiency especially for risk users in a vulnerable peripheral region of the capital of Brazil served free of charge by the Unified Health System.

Description of the Problem

We conducted a content validation by primary health care nurses, pharmacists and physicians (PHC) by Delphi technique, applied in two phases from November to December 2018, through a questionnaire that evaluated clarity, relevance and feasibility of performing Illustrated Prescription, with field for comments. We used a 4-point Likert scale, Cronbach Alpha for reliability and Content Validation Index (CVI) with agreement above 0.8 indicating validation. Project approved by the Ethics Committee - FEPECS.

Results

Round-1: 29 out of 32 items were validated, with Cronbach's alpha .9812. Round-2: Included 4 new items, guidelines for indicating whole tablet, adjustment of the font size and color column size of elastic alloys, all items being validated and Cronbach's alpha of 0.9876.

Lessons

Validation ensures clarity and correction of the Illustrated Prescription, being extremely important for dissemination of the visual model for prescribing. It allows future evaluation of increased drug adherence and risk reduction related to incorrect use of medications especially for illiterate or visually impaired users.

Key messages

Illustrated Prescription is a validated tool that opens up the possibility of greater safety and efficient use of chronic medications, especially for vulnerable users with chronic diseases. Validation ensures clarity and correction of the Illustrated Prescription, being extremely important for dissemination of the visual model for prescribing.

Allergy to beta-lactam antibiotics in children: Risk factors for a positive diagnostic work-up

BACKGROUND

Allergy to beta-lactam (βL) antibiotics is highly reported in children, but rarely confirmed. Risk factors for a positive diagnostic work-up are scarce. The primary aim was to characterize the cases of children with confirmed βL allergy, investigating potential risk factors. Secondary aims were to assess the prevalence of allergy to βL in this population and to confirm the safety of less extensive diagnostic protocols for milder reactions.

METHODS

We reviewed the clinical data from all children evaluated in our Department for suspected βL allergy, over a six-year period.

RESULTS

Two hundred and twenty children (53% females) with a mean age of 6.5±4.2 years were evaluated. Cutaneous manifestations were the most frequently reported (96.9%), mainly maculopapular exanthema (MPE). The reactions were non-immediate in 59.5% of the cases. Only 23 children (10.5%) were diagnosed with allergy to βL. The likelihood of βL allergy was significantly higher in children with a family history of drug allergy (p<0.001) and in those with a smaller time period between the reaction and the study (p=0.046). The probability of not confirming βL allergy is greater in children reporting less severe reactions (p<0.001) and MPE (p<0.001). We found the less extensive diagnostic protocol in milder reactions safe, since only 4.2% of the children presented a positive provocation test (similar reaction as the index reaction).

CONCLUSION

This study highlights family history of drug allergy as a risk factor for a positive diagnostic work-up. Larger series are required, particularly genetic studies to accurately determine future risk for βL allergy in children.

Pretreatment hemoglobin level as a prognostic factor in patients with locally advanced head and neck squamous cell carcinoma

Aim

Evaluate pretreatment hemoglobin values as a prognostic factor in patients with locally advanced head and neck squamous cell carcinoma treated with concurrent chemoradiotherapy.

Background

Anemia is one of the most prevalent laboratory abnormalities in oncological disease. It leads to a decrease in cellular oxygen supply, altering radiosensitivity of tumor cells and compromising therapeutic outcomes.

Materials and Methods

Retrospective evaluation of patients with HNSCC treated with cCRT. Primary and secondary endpoint was to evaluate the correlation of Hb levels (≥12.5 g/dL or <12.5 g/dL) at the beginning of cCRT with overall survival (OS) and progression-free survival (PFS), respectively.

Results

A total of 108 patients were identified. With a median follow-up of 16.10 months median OS was 59.70 months for Hb ≥12.5 g/dL vs. 14.13 months for Hb <12.5 g/dL (p = 0.004). PFS was 12.29 months for Hb ≥12.5 g/dL and 1.68 months for Hb <12.5 g/dL (p = 0.016).

Conclusions

In this analysis, Hb ≥12.5 g/dL correlated with significantly better OS and PFS. Further studies are needed to validate these findings.

HER family in cancer progression: From discovery to 2020 and beyond

The human epidermal growth factor receptor (HER) family of receptor tyrosine kinases (RTKs) are among the first layer of molecules that receive, interpret, and transduce signals leading to distinct cancer cell phenotypes. Since the discovery of the tooth-lid factor-later characterized as the epidermal growth factor (EGF)-and its high-affinity binding EGF receptor, HER kinases have emerged as one of the commonly upregulated or hyperactivated or mutated kinases in epithelial tumors, thus allowing HER1-3 family members to regulate several hallmarks of cancer development and progression. Each member of the HER family exhibits shared and unique structural features to engage multiple receptor activation modes, leading to a range of overlapping and distinct phenotypes. EGFR, the founding HER family member, provided the roadmap for the development of the cell surface RTK-directed targeted cancer therapy by serving as a prototype/precursor for the currently used HER-directed cancer drugs. We herein provide a brief account of the discoveries, defining moments, and historical context of the HER family and guidepost advances in basic, translational, and clinical research that solidified a prominent position of the HER family in cancer research and treatment. We also discuss the significance of HER3 pseudokinase in cancer biology; its unique structural features that drive transregulation among HER1-3, leading to a superior proximal signaling response; and potential role of HER3 as a shared effector of acquired therapeutic resistance against diverse oncology drugs. Finally, we also narrate some of the current drawbacks of HER-directed therapies and provide insights into postulated advances in HER biology with extensive implications of these therapies in cancer research and treatment.

Lisbon Burn Centre experience with intentional burn injuries

Burn injury as a form of hetero or auto-aggression accounts for a significant amount of admissions to a Burn Care Unit, with epidemiologic and clinical specificities. To investigate the differences in risk factors, psychiatric comorbidities, injury severity and mortality among adult patients with accidental or intentional burns, we analyzed routinely collected data from a Central Hospital Burn Unit over a period of 6 years (January 1st, 2010 to December 31st, 2015). We identified 22 intentional burn patients (5%) among all the admissions to our Burn Unit. When compared to the accidental burns, the intentional burn patients are significantly younger (45.7±14.7 vs. 54.9±19.9), have a bigger percentage of body surface area burned (35% vs. 14%), have a higher incidence of inhalation burn (50% vs. 22.8%) and higher mortality (18.2% vs. 6.1%). Fifty-five percent of cases of intentional burns were self-inflicted. Self-inflicted burns have a worse prognosis than hetero-aggressions (inhospital mortality 25% vs. 10%). Psychiatric comorbidities were largely more prevalent in the intentional burn patients (59% vs. 6.6%), namely mood disorders. Compared to patients with accidental burns, intentional burn patients have worse clinical condition and prognosis. A multidisciplinary preventive approach, looking at the specificities of the violent nature of the lesions and identifying risk groups may reduce the incidence and severity of this type of burns.

Predicting incomplete basal cell carcinoma excisions - a large multidisciplinary retrospective analysis in a tertiary center

Introduction: Surgical treatment of basal cell carcinomas is often performed by physicians with different surgical backgrounds. Collecting data from different surgical departments would better reflect their real-life surgical management.Objectives: To identify the rate, recurrence risk, and predictive factors accordingly to their relative contribution for an incomplete basal cell carcinoma excision in a large multidisciplinary real-life settingMethods: Retrospective cohort study of 2305 surgically treated lesions in different departments of a tertiary center.Results: There was a rate of incomplete excisions (15%) and a recurrence rate (35.5% vs. 6.8% in incomplete vs. complete excisions (p < .001)). A third of incompletely excised basal cell carcinoma (BCC) will recur over time. Stratified by relevancy, high-risk histological subtypes (micronodular (OR 5.10 - p < .001) and morpheaform (OR 5.42 - p < .001), smaller specimen sizes ( <0.5 cm or 0.5-1 cm, OR 3.99 and 2.49, respectively, p < .001) high-risk locations (OR 3.06 on the nose, OR 2.77 on the eyelids, p < .001), and recurrent BCCs (OR 1.72, p < .001). are the best predictors of an incomplete excision.Conclusions: Acknowledging the rate, recurrence risk and predictive factors for incomplete excisions may be beneficial for optimal preoperative planning and to prevent unwarranted re-interventions, morbidity, and healthcare costs.

HIV screening of tuberculosis patients in Portugal: what are we missing?

BACKGROUND

Knowledge of human immunodeficiency virus (HIV) status is essential to effectively manage both tuberculosis (TB) and HIV infection. This is why the World Health Organization (WHO) recommends routine HIV testing in all TB patients.

OBJECTIVE

To determine the number of TB patients with unknown HIV status in Portugal and to identify the factors associated with unknown HIV status.

METHODS

A retrospective study of all TB notifications from 2008 to 2014 in Portugal was conducted. A multiple logistic regression model was used to evaluate the association of sociodemographic and clinical factors with unknown HIV status.

RESULTS

We examined the records of 18 445 patients with TB notification, 2402 of whom (13%) had unknown HIV status. Unknown HIV status was positively associated with age 65 years (adjusted odds ratio [aOR] 1.208, 95%CI 1.037-1.408) and extra-pulmonary TB (aOR 1.381, 95%CI 1.252-1.523), but negatively associated with unemployment (aOR 0.755, 95%CI 0.637-0.895), alcohol dependence (aOR 0.809, 95%CI 0.682-0.959) and drug dependence (aOR 0.566, 95%CI 0.449-0.713).

CONCLUSION

Risk perception is the most important barrier to complete knowledge of HIV status in TB patients in Portugal. Given the importance of HIV screening in TB patients, every effort should be made to ensure that all TB patients undergo HIV screening.

Choroid thickness profile in patients with lupus nephritis

BACKGROUND

Choroidopathy is a rare manifestation of systemic lupus erythematosus (SLE). This entity is associated with active phases of severe SLE and it is frequently accompanied by acute kidney failure, central nervous system involvement and coagulopathy.

PURPOSE

To evaluate the choroid thickness of patients with lupus nephritis (LN) without choroidopathy, and to compare this with that of age-matched SLE patients without LN and healthy control subjects.

STUDY DESIGN

Cross-sectional case control study.

MATERIAL AND METHODS

Fifteen women with LN in remission phase (study group), 15 women with SLE in remission without LN (SLE control group), and 15 healthy women (healthy control group), without ocular diseases or significant refractive error, were recruited. Full ophthalmological examination and a macular optical coherence tomography in enhanced depth imaging mode were performed. The choroid thickness was measured at nine macular points and six lines of mean choroidal thickness were determined. A comparative analysis between the three groups was performed using the one-way ANOVA test and the paired t-test. The choroid thickness of patients under corticotherapy was also compared to that of patients without corticotherapy. Additionally, the correlation between choroid thickness and disease duration was evaluated using the Pearson analysis.

RESULTS

The mean macular choroidal thickness was 295.73 ± 67.62 μm in the study group, 233.34 ± 41.01 µm in the SLE control group, and 240.98 ± 37.93 μm in the control group ( p = 0.00006 and p = 0.0003, respectively). Additionally, the choroid thickness was significantly thicker than in the SLE and healthy control groups at the foveal ( p = 0.004 and p < 0.000), nasal ( p < 0.000 and p = 0.001), superior ( p = 0.002 and p < 0.000) and inferior ( p < 0.000 and p = 0.001) mean lines. The choroidal thickness in this group was not associated with the duration of the disease. The subgroup of patients with LN under corticotherapy did not reveal a significantly different choroidal thickness.

CONCLUSION

This study suggests a relationship between LN and choroidal changes, which may represent an increased risk for choroidopathy in these patients. Choroid thickening was not related with the duration of the disease. This thickening may be correlated with histopathological changes similar to those occurring in kidney glomeruli.

Tumores de Células Germinativas Testiculares: Casuística do Hospital CUF Infante Santo

INTRODUÇÃO: Os tumores de células germinativas são tumores raros, constituindo 1% a 2% do total das neoplasias malignas e cerca de 5% do total dos tumores malignos urológicos. Originam-se no testículo em mais de 90% dos casos.MÉTODOS: Os autores reveem os casos de tumores de células germinativas, incluindo o diagnóstico, tratamento e follow-up, ocorridos no Hospital CUF Infante Santo num período de mais de 15 anos, compreendido entre agosto de 1999 e novembro de 2014.RESULTADOS: A série compreende 33 doentes, todos submetidos inicialmente a orquidectomia radical, diagnóstica e terapêutica, estando o maior número de doentes, 21 (63,6%) em estádio I. Destes, 14 (66% dos estádios I), vieram a fazer tratamento pós-orquidectomia. Todos os doentes em estádios mais avançados efetuaram tratamento pós-cirúrgico. Verificaram-se apenas quatro recidivas (12,1%), ocorridas em mediana 20 meses pós-diagnóstico e todas salvas por posterior tratamento.CONCLUSÃO: A toxicidade parece-nos aceitável, não tendo ocorrido nenhuma morte relacionada com qualquer modalidade de tratamento. Com uma mediana de follow-up de 59 meses à data da conclusão da revisão, a sobrevivência livre de doença foi de 100%.

Occipital blood-brain barrier permeability is an independent predictor of visual outcome in type 2 diabetes, irrespective of the retinal barrier: A longitudinal study

Blood-brain barrier (BBB) permeability in type 2 diabetic patients has been previously shown to be altered in certain brain regions such as the basal ganglia and the hippocampus. Because of the histological and functional similarities between the BBB) and the blood-retinal barrier (BRB), we aimed to investigate how the permeability of both barriers predicts visual outcome. We included 2 control groups (acute unilateral stroke patients, n = 9; type 2 diabetics without BRB leakage n = 10) and a case study group of type 2 diabetics with established BRB leakage (n = 17). We evaluated sex, age, disease duration, metabolic impairment, retinopathy grade and BBB permeability as predictors of visual acuity at baseline, 12  and 24 months in the type 2 diabetics without BRB leakage group and the case study group. We have also explored differences in BBB permeability in the occipital lobe and frontal lobe in the 3 different groups. K^trans (volume transfer coefficient) and V_p (fractional plasma volume) were estimated. The BBB permeability parameter V_p was higher in the case study group compared to the unaffected hemisphere of the stroke patient control group, suggesting vascular dynamics were changed in the occipital lobe of type 2 diabetics with established BRB leakage. These patients showed a significant correlation between glycated hemoglobin (HbA1C) levels and occipital and frontal K^trans . We report for the first time that occipital BBB permeability is an independent predictor of visual acuity at baseline, as well as at 12 and 24 months, in type 2 diabetics with established BRB leakage. Our results suggest that occipital BBB permeability might be an independent biomarker for visual impairment in patients with established BRB leakage.