Ethem Kavukcu

Chronic noncancer pain management in primary care: family medicine physicians' risk assessment of opioid misuse.

Abstract Objective: The majority of patients with chronic noncancer pain (CNCP) are managed in the primary care settings. The primary care family physician (PCFP) generally has limited time, training, or access to resources to effectively evaluate and treat these patients, particularly when there is the added potential liability of prescribing opioids. The aim of this study is to make a favorable change in PCFPs’ knowledge, attitudes, and practices about opioid use in CNCP via education on assessment of the risk of opioid misuse. Materials and methods: The universe of this cross-sectional study comprised 36 family physicians working at Family Health Centers affiliated to Antalya Provincial Directorate of Health who volunteered to participate in the study. Initially, a survey on patients risk assessment was performed in both intervention and control groups; whereas the intervention group received education on assessment of the risk of opioid misuse, the control group did not. The survey was repeated after 6 months and the intervention group underwent a core examination. Data obtained were analyzed with Statistical Package for the Social Sciences 18.0 statistics program. Intervention and control groups were compared. Additionally, pre- and post-education results of the intervention group were also compared. Results: About 61.1% of family physicians reported concern and hesitation in prescribing opioids due to known risks, such as overdose, addiction, dependence, or diversion, and agreed that family physicians should apply risk assessment before opioid use in CNCP. Only 16.6% of PCFP reported that risk assessment is not so necessary, whereas 22.2% of PCFP were undecided. Although 47.2% of the family physicians expressed a willingness to apply risk assessment before starting opioids, the rate of eagerness increased markedly to 77.7% after the education, but the rate of increase in practicing was not statistically significant. Conclusion: Knowledge and competency of the family physicians in managing CNCP were improved as was expected. Although the rate of eagerness about risk assessment of opioid misuse was increased, expected increase in the rate of using risk assessment was not achieved. Further studies are needed to identify the reasons of the difficulties on changing the attitudes and practices of primary care physicians about this subject.

Discovery of asymptomatic Krukenberg tumors diagnosed during caesarean section: therapy with hyperthermic intraperitoneal chemotherapy.

Abstract We report a case of the discovery of asymptomatic Krukenberg tumors in a 37–year-old woman in the 37th week of pregnancy during caesarean section. Subsequent gastroscopy revealed an adenocarcinoma of the stomach as the primary tumor site. The patient was treated with hyperthermic intraperitoneal chemotherapy (HIPEC). Tumor surgery (Partial parietal peritonectomy and partial gastrectomy) and HIPEC treatment were successful, with no complications found during follow-up. Use of HIPEC seems to be a promising option after radical surgery, including its use in patients with gastric tumors that are in advanced stages, and use in patients who have tumors with poor prognoses, such as Krukenberg tumors.

Diagnosis and treatment of deep-vein thrombosis and approach to venous thromboembolism in obstetrics and gynecology

Deep vein thrombosis (DVT) is a common condition in which the approach to its diagnosis has evolved over the years. Currently, an algorithm strategy combining pre-test probability, D-Dimer testing and compression ultrasound imaging allows for safe and convenient investigation of suspected lower-extremity thrombosis. Patients with low pre-test probability and a negative D-Dimer test result can have proximal DVT excluded without the need for diagnostic imaging. The mainstay of treatment of DVT is anticoagulation therapy, whereas interventions such as thrombolysis and placement of inferior vena cava filters are reserved for special situations. The use of low-molecular-weight heparin (LMW) allows for outpatient management of most patients with DVT. The duration of anticoagulation therapy depends on whether the primary event was idiopathic or secondary to a transient risk factor. More research is required to optimally define the factors that predict an increased risk of recurrent DVT to determine which patients can benefit from extended anticoagulant therapy. DVT is also a serious problem in the antenatal and postpartum period of pregnancy. Thromboembolic complications are the leading cause of both maternal and fetal morbidity and mortality. The incidence of venous thromboembolism during normal pregnancy is six-fold higher than in the general female population of childbearing age. The treatment of DVT during pregnancy deserves special mention, since oral anticoagulation therapy is generally avoided during pregnancy because of the teratogenic effects in the first trimester and the risk of fetal intracranial bleeding in the third trimester. LMW heparin is the treatment of choice for DVT during pregnancy. If acute DVT occurs near term, interrupting anticoagulation therapy may be hazardous because of the risk of pulmonary embolism. In this situation, placement of a retrievable inferior vena cava filter must be considered. However, there is no consensus as to what the appropriate dose should be and whether anti-Xa levels need to be monitored.

Left Atrial Appendage (LAA) Closure-Device Disengagement as a Serious Complication and How it Can Be Easily Removed

A stroke attack in the brainstem area as a serious complication of atrial fibrillation (AF) in a 51 year old woman with known paroxysmal AF (CHADS(2) score 3) was treated with LAA occlusion procedure after the complication of arterial bleeding secondary to anticoagulation therapy. LAA closure device embolisation was developed following the LAA occlusion procedure. The device was located and removed successfully from the systemic circulation.

Quaternary prevention: First, do not harm

Clinical prevention, under the influence of public health, has been organised in a chronological manner since the middle of the 20th century. A paradigm shift from a chronological to a constructivist relationship-based preventive pattern of care1 offers new insights into the practice of doctors. This paradigm shift brings to light the concept of quaternary prevention, a critical look at medical activities with an emphasis on the need not to harm. Quaternary prevention addresses the fundamental question of what constitutes too much or too little medicine. It is the fourth form of disease prevention, but also the fourth frame of action for family doctors (Figure 1). The shift from time-based prevention towards a relationship-based organisation offers new perspectives into physicians’ work. The physicians observe themselves and question the ethical limits of their activities. In this sense, quaternary prevention is aimed more at the doctor than the patient. Moreover, the four definitions of prevention, published in the Wonca Dictionary of Family Medicine,2 offer a structured way to discuss the activities of family doctors, including ethical considerations on the patient-doctor encounter. Quaternary prevention, also known as P4, is a new term for an old concept: first, do not harm. This concept enforces disciplines and attitudes such as evidence-based medicine, quality assurance, defensive medicine, avoiding abusive nosographic diagnoses and ethical issues including those linked to overinformation, and overmedicalisation.3

Severe Valvular Regurgitation: An Unexpected Complication During Transapical Aortic Valve Implantation Treated Successfully with the "Valve-in-Valve" Procedure.

Severe symptomatic aortic stenosis (AS) in a multimorbid 77 year old female was treated with transapical aortic valve implantation with a 23 mm Edwards Sapien valve. Severe valvular regurgitation following implantation, probably due to structural valve failure, was treated successfully with a second valve-in-valve implantation. During a follow-up time of 2,5 years no further problems occurred.