Questions for this month's clinical challenge are based on articles in this issue. The clinical challenge is endorsed by the RACGP Quality Improvement and Continuing Professional Development (QI&CPD) program and has been allocated four Category 2 points (Activity ID: 109894). Answers to this clinical challenge are available immediately following successful completion online at http://gplearning. Read More
Background: Advance care planning (ACP) can positively affect end-of-life care experiences. However, uptake of ACP completion is low. The aim of this study was to investigate whether co-locating ACP facilitators in general practice increased participation METHODS: Barwon Health commenced promoting its ACP program in 2008. Read More
Background: More than one-third of people living with chronic hepatitis B virus (HBV) in Australia have not been diagnosed. The aim of this study was to assess general practitioners' (GPs') knowledge and practices regarding chronic HBV diagnosis, and identify opportunities to improve testing rates.
Methods: A cross-sectional survey was conducted with GPs working in Victoria, Australia. Read More
Background: Hyponatraemia is one of the most commonly encountered electrolyte abnormalities in general practice. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is an important but under-recognised cause.
Objective: This article explores the presentation, investigation, diagnosis and management of SIADH. Read More
Background: Six per cent of patients who present to primary care have borderline personality disorder (BPD). Mothers with full or partial features of BPD, often undiagnosed and perhaps previously functioning adequately enough on the surface, may rapidly be-come emotionally dysregulated by the normal needs of an infant. Family and maternal functioning can rapidly destabilise. Read More
Background: Male urinary incontinence adversely affects health-related quality of life and is associated with significant psychosexual and financial burden. The two most common forms of male incontinence are stress urinary incontinence (SUI) and overactive bladder (OAB) with concomitant urge urinary incontinence (UUI).
Objective: The objectives of this article are to briefly review the current understandings of the pathophysiological mechanisms in SUI and OAB/UUI, and offer a set of practical, action-based recommendations and treatment strategies. Read More
Background: Peyronie's disease is a relatively common condition in urological practice, but is still poorly identified and understood in the wider medical community and by most of the public. Identifying the condition and appropriate referral for expert opinion can significantly lessen the physical and psychological effect on patients.
Objective: The objective of this article is to provide general practitioners with a concise and updated review of Peyronie's disease, with the aim of helping them to provide appropriate advice to their patients. Read More
Background: Upper urinary tract stones are a common problem in Australia, with an incidence of 0.13% per year, and a lifetime prevalence of up to 15% in males and 8% in females. Many of these patients first present to general practitioners (GPs), so a thorough understanding of the diagnosis, treatment and prevention of stone disease is an important part of any GP's arsenal. Read More
Background: A male factor contributes to infertility in approximately 50% of couples who fail to conceive, causing significant psychosocial and marital stress.
Objective: This article reviews the general practitioner's (GP's) evaluation of male infertility and indications for referral to a male infertility specialist, and gives an overview of the specialist management of male infertility.
Discussion: Male infertility can result from anatomical or genetic abnormalities, systemic or neurological diseases, infections, trauma, iatrogenic injury, gonadotoxins and development of sperm antibodies. Read More
Background: Sleepwalking is a relatively common and innocuous arousal disorder during non‑rapid eye movement sleep.
Objective: This paper provides a review of the most recent science on sleepwalking to guide clinical decision-making.
Discussion: Most patients who sleepwalk do not require treatment, but comorbid sleep disorders that result in daytime tiredness, and behaviour and emotional problems require assessment and interventions. Read More
Background: Data linkage has been defined as 'the bringing together from two or more different sources, data that relate to the same individual, family, place or event'. Australia is one of few countries that has invested significantly in the creation of data linkage facilities.
Objective: This paper provides an overview of data linkage and its relevance to general practice research. Read More
Background: Medical practitioners are often caught between a patient who is reluctant to provide their employer with personal health information and an employer who is requesting more detailed health information.
Objective: This article outlines the rights and responsibilities of employees and employers with regards to the provision of personal health information within employment, and how medical practitioners can assist in advocating for their patient. Topics covered include legal requirements for medical certificates; when certificates can be questioned by an employer; and whether employers can request additional health information from a general practitioner (GP) or independent specialist. Read More
Background: Seven per cent of Australian adults report avoiding wheat products for the relief of symptoms. The objective of this study was to explore the experiences, symptoms, influences and beliefs that may explain the tendency for this behaviour to occur pre-dominantly in the absence of a reported medical diagnosis or expert dietary supervision.
Methods: Data were collected through preliminary questionnaires and semi-structured interviews with 35 self-identified symptomatic individuals who avoid consumption of wheat-based products without a diagnosis of coeliac disease or wheat allergy. Read More
PhD, Discipline of General Practice, School of Medicine, The University of Queensland, Brisbane, QLD.
Background: The objective of this article was to explore the information needs of consumers using statins.
Methods: Calls made to a national medicines call centre in Australia were analysed. Where question narratives were available electronically (n = 1486), the main concerns were identified using a coding scheme. Read More
Background: Hidradenitis suppurativa (HS) is a chronic inflammatory disease presenting in intertriginous areas. HS is associated with a number of disease-modifying comorbidities, including metabolic syndrome and androgen dysfunction, and smoking.
Objective: This review provides a synopsis of the aetiology and diagnosis of HS, and an overview of management for this often devastating disease. Read More
Background: General practitioners (GPs) are uniquely placed to help adolescents take control of managing their chronic illness, and provide continuity of care during the transition to adulthood. This is dependent on a well-established therapeutic relationship with a young person and their family.
Objective: The aim of this article is to address the preferences of young people with a chronic illness in dealing with doctors. Read More
Background: Nearly 20% of all inflammatory bowel disease (IBD) is diagnosed in children and adolescents, where it follows a more compli-cated and aggressive course than adult-onset IBD. General practitioners (GPs) have a pivotal role in early diagnosis, and monitoring and supporting children and families with IBD.
Objective: This article will focus on recognising key differences between paediatric-onset IBD and adult-onset IBD, proposed treatment targets, and practical issues in the management of adolescents with IBD. Read More
Background: Adolescence can be a time when rheumatological conditions present to the general practitioner for diagnosis and management. Diagnosis of rheumatic disease during adolescence and earlier childhood often brings additional challenges such as those relating to body image, schooling and recreational activities, friendships and relationships, compliance with medications and independence with healthcare needs.
Objective: This article highlights rheumatological conditions that have relevance during adolescence and describes the approach to the history, examination and investigation of young people with rheumatic disease. Read More
Background: Hypertrophic cardiomyopathy (HCM) is the most common inherited cardiac disease, which generally manifests during adolescence. Adolescents may be diagnosed incidentally, following the investigation of symptoms, or during family screening. Early recognition may prevent sudden cardiac death. Read More
Background: We previously showed that general-practice based screening for diabetic retinopathy significantly improves recording of screening outcomes and follow-up for Australians with type 2 diabetes. In 2016, two Medicare Benefits Schedule item numbers were launched to support screening in general practice. However, there is little evidence-based information to guide practices in successfully implementing screening models for diabetic retinopathy. Read More
Background: Few studies have investigated older patients with regards to general practice follow-up after an emergency department (ED) admission. We measured the proportion of older patients given explicit general practice follow-up instructions who sought care by day seven after an ED admission.
Methods: Patients discharged from Fairfield Hospital ED (south-western Sydney) who were 65 years and older were approached for a structured telephone interview. Read More
Objective: A significant proportion of Australians with chronic hepatitis B (CHB) remains undiagnosed and unaware of their risk of liver disease and cancer. This study explored the hepatitis B testing and diagnostic experiences of people with CHB, general practitioners (GPs) and primary care nurses.
Methods: Semi-structured interviews were conducted with people who have CHB (n = 19), GPs (n = 14) and nurses (n = 5). Read More
Background: Despite available Medicare Benefits Schedule subsidies, it has been suggested that screening and treatment for osteoporosis are under-accessed in Australia, particularly in patients ≥70 years. This study describes the rate of osteoporosis treatment in those aged ≥70 years in regional New South Wales as identified in the electronic medical records (EMR) of 11 general practices.
Methods: EMR data were extracted using a Canning Tool adaptation. Read More
Background: Nasal obstruction is among the most common complaints to the general practitioner (GP). Causes can be divided into mucosal causes or anatomical abnormalities. Most mucosal pathologies can be managed effectively in the primary care setting, with referral to the otolaryngologist in cases that are resistant to medical therapy and in cases of structural anomaly. Read More
Background: Chronic lymphocytic leukaemia (CLL) is the most common lymphoproliferative disease in Australia. Improvements in the understanding of this disease have led to drastic changes in regards to diagnosis, management and prognosis.
Objective: The aim of this article is to give an updated approach to the diagnosis, investigation, monitoring and new treatments of CLL. Read More
Background: Fragile X-associated disorders are a family of inherited disorders caused by expansions in the Fragile X Mental Retardation 1 (FMR1) gene. Premutation expansions of the FMR1 gene confer risk for fragile X-associated primary ovarian insufficiency and fragile X-associated tremor ataxia syndrome, as well as other medical and psychiatric comorbidities. Premutation expansions of the FMR1 gene are common in the general population. Read More
Background: Genitourinary syndrome of menopause (GSM) is the new term for vulvovaginal atrophy (VVA). Oestrogen deficiency symptoms in the genitourinary tract are bothersome in more than 50% of women, having an adverse impact on quality of life, social activity and sexual relationships. GSM is a chronic and progressive syndrome that is underdiagnosed and undertreated. Read More
Background: Obesity is a serious, chronic, relapsing disease of energy regulation, with strong genetic and early-life environmental determinants. Pharmacotherapy can be a useful adjunct to lifestyle intervention in effecting and maintaining clinically meaningful weight loss.
Objective: The aim of this article is to discuss the role of pharmacotherapy in obesity management. Read More
Background: Bariatric-metabolic surgery has emerged as an attractive option that offers significant and durable weight loss in the treatment of clinically severe obesity. Given the high prevalence of obesity, and growing numbers of bariatric-metabolic surgeries performed, primary care physicians increasingly encounter patients who have had, or are considering, bariatric-metabolic surgery.
Objective: The aim of this article is to provide guidance on common issues pertaining to bariatric-metabolic surgery that general practitioners (GPs) face, including patient selection, preoperative work-up, acute and long-term complications following the surgery, and long-term lifestyle and nutritional support. Read More
Background: Obstructive sleep apnoea (OSA) and obesity are two common conditions affecting the Australian population; obesity is the major risk factor for OSA.
Objective: The objectives of this article are to review the interactions between obesity and OSA, including the increased cardiovascular risk, and highlight the importance of using OSA diagnosis as a critical time to address obesity itself and other cardiovascular risk factors.
Discussion: Snoring and symptoms of OSA frequently worsen during periods of rapid weight gain. Read More
Background: The prevalence and cost of overweight and obesity are projected to continue to rise in our current sedentary, energy-rich environment. The heritability of obesity is reported to be 40-80%.
Objective: The objectives of this article are to review recent genetic discoveries about the basis of human obesity; describe familial or syndromic obesity, which is rare but presents early and should, if suspected, be referred for full specialist diagnosis of the underlying genetic disorder; and summarise immediate implications for general practice. Read More
Background: For research to be ethically acceptable, the potential benefits must justify any risks involved for participants. Dissemination of research findings through publication is one way of creating benefit, but not all researchers intend to publish their research. Other factors, such as lack of size or representativeness, generalisability or innovativeness, or negative findings mean the research is unlikely to be published in a peer-reviewed medical journal. Read More
Background: Procedural skills are an essential component of general practice vocational training. The aim of this study was to investigate the type, frequency and rural or urban associations of procedures performed by general practice registrars, and to establish levels of concordance of procedures performed with a core list of recommended procedural skills in general practice training.
Methods: A cross-sectional analysis of a cohort study of registrars' consultations between 2010 and 2016 was undertaken. Read More
Grad Assoc Physio, MSc PhD, Senior Lecturer, Clinical and Rehabilitation Sciences, Faculty of Health Sciences, University of Sydney and Conjoint Senior Lecturer, University of New South Wales, New South Wales.
Background: Physiotherapy plays an important role in the health of many Australians. The aims of this study were to assess changes in the rate of general practitioner (GP) referral to physiotherapists in Australia from 1998 to 2014, and to determine patient characteristics associated with increased likelihood of such referral.
Methods: Secondary analysis was undertaken of data from the Bettering the Evaluation and Care of Health program using weighted encounter data years 1998-99 to 2014-15 inclusive. Read More
Background: Dispensing data suggest potential issues with the quality use of medicines for airways disease.
Objective: The objective of this article was to describe the management of asthma and chronic obstructive pulmonary disease (COPD) in general practice, and investigate the appropriateness of prescribing.
Methods: The method used for this study consisted of a national cross‑sectional survey of 91 Australian general practitioners (GPs) participating in the Bettering the Evaluation and Care of Health (BEACH) program. Read More
Background: Media reports suggest that growth in urgent, after-hours Medicare Benefits Schedule (MBS) claims has coincided with an increasing number of after-hours medical deputising services (AHMDSs). This article assesses these claims in the context of an increasing presence of AHMDSs.
Methods: Retrospective analysis of MBS claims data for general practitioner (GP) after-hours items from 2010-11 to 2015-16 was conducted. Read More
Background: The objective of this article was to alert general practitioners (GPs) to the increase in ocular syphilis in the context of a worsening epidemic of syphilis among men who have sex with men (MSM).
Methods: This study used a retrospective case review of ocular syphilis cases that presented to the Royal Victorian Eye and Ear Hospital from January 2015 to August 2016.
Results: Twelve patients (19 eyes) were identified, including 11 males. Read More
Background: The common use of cross-sectional imaging for the investigation of abdominal and thoracic illness has resulted in the rise of the incidentally identified adrenal mass, or incidentaloma, which presents a diagnostic and management dilemma for the primary care physician.
Objective: This article provides a framework for the investigation and management of incidental adrenal masses.
Discussion: Adrenal incidentalomas are found in approximately 3-4% of abdominal computed tomography (CT) scans. Read More
Background: Greater numbers of people are travelling to places at high altitude each year. Altitude illness is common in places at high altitude and may be life-threatening. General practitioners (GPs) are best placed to provide evidence-based advice to keep travellers well informed of the possible risks they may encounter in places at high altitude. Read More
Background: Women who are perimenopausal are at risk of unintended pregnancy despite relatively low fertility at this stage. Contraceptive choice can be limited by increased comorbidities, but the UK Medical Eligibility Criteria (UKMEC) system provides a framework for safe prescribing.
Objective: This article provides evidence-based guidance on contraceptive options, and information to support decision-making about stopping contraception at menopause. Read More
Background: Many women report gaining weight as they transition through menopause. For most, the weight gain is modest and can be reduced with a conscious effort to limit energy intake and increase energy expenditure. However, many women who are already overweight and obese will gain more weight as they approach menopause. Read More
Background: Premature ovarian insufficiency (POI), defined as amenorrhoea due to the loss of ovarian function before 40 years of age, can occur spontaneously or be secondary to medical therapies. POI is associated with cardiovascular morbidity, osteoporosis and premature mortality. Women with POI present in primary care with menstrual disturbance, menopausal symptoms, infertility and, often, significant psychosocial issues. Read More