BACKGROUND Bipolar disorder affects about 1% of Australians and impacts severely on relationships, careers and general functional capacity. General practitioners are central in the management of patients with bipolar disorder. OBJECTIVE To update clinicians on the recognition, diagnosis and management of bipolar disorder in light of recent research. DISCUSSION There is growing concern about the over-diagnosis of bipolar disorder, and increasing evidence that bipolar depression may present differently to unipolar depression. Antipsychotics are the initial agents of choice for the acute treatment of mania. For preventive treatment, lithium and atypical antipsychotics have the strongest evidence base. Lithium has been shown to be more effective than valproate. The main effect of lithium and most of the atypical antipsychotics is on prevention of manic relapse; only olanzapine and quetiapine also protect against depression. Lamotrigine is an agent with evidence for prevention of depressive relapse, but have minimal activity against mania. The role of antidepressants remains contentious, while there is strong support for quetiapine. Finally, there is growing evidence from randomised controlled trials of the benefit of psychological therapies in conjunction with medications.
There are many more 'family matters' issues worthy of reflection, but the examples represent some of the more common personal dilemmas facing medical practitioners, and in particular women doctors, based on both my own experience and conversations with colleagues. There are no simple or universally appropriate answers to any of the scenarios; I have not attempted to suggest solutions to any of the issues raised, but hope that some situations outlined will evoke empathy and promote thought, discussion or debate about ways that individual doctors could deal with such matters.
Spinal cord tethering due to a tense filum terminale may present with clinical features that include voiding dysfunction, back and leg pain, musculoskeletal and/or sensorimotor abnormalities of the distal legs and feet, and gait dysfunction. External dysraphic markers may be present over the midline lumbosacral spine, including skin dimples, hemangiomata, atretic tails or skin tags, superficial dermal sinus tracts, and/or bifid or Y-shaped gluteal folds. Magnetic resonance imaging (MRI) remains the most clinically useful and definitive diagnostic modality for tethered spinal cord and should be used to assess the filum terminale, position of the conus tip, and presence of syringomyelia. Spinal cord tethering may be successfully treated with transection of the filum terminale. Careful peri-operative assessment and follow-up of voiding dysfunction and syringomyelia will optimize long-term outcomes.
www.peanut-institute.org The American diet is taking a major shift towards plant-based eating. For the first time ever, the 2010 Dietary Guidelines for Americans tells us loud and clear: eat a plant-based diet that includes plants as an important source of protein.1 In the 2010 report of the Dietary Guidelines Advisory Committee (DGAC), peanuts were highlighted as the nut eaten most by Americans. Peanut butter and peanuts have more protein than any other nut, and because of their popularity, peanuts are a major plant protein source for all Americans. The DGAC stated that adding peanuts to our meals “provides an important source of plant protein and other nutrients” we need each and every day.
DISCUSSION People who are homeless or marginalised have poor engagement with mainstream healthcare services. The aim of this study was to explore patient and staff perspectives of a street-based, primary health service, to help identify factors influencing patient access and management. A qualitative study was undertaken from April to September 2016. Interviews (n = 27) explored patients’ experiences of accessing healthcare services. Interviews with allied service staff (n = 5) explored referral pathways and patients’ access to healthcare. Factors influencing patients’ willingness to access primary healthcare through the street health service were identified as doctor–patient empathy, better understanding of patient circumstances, fostering of social capital, facilitating referral pathways and supporting the transition to mainstream general practice as circumstances improve. Hospital discharge planning and follow-up management were identified as gaps in the continuity of service. Ease of access provided by a street-based health service facilitates access to the healthcare system for homeless and marginalised patients. .
BACKGROUND As sexual wellbeing is an important aspect of good general health, and sexual difficulties are a concern for 20-40% of the adult population, general practitioners (GPs) have a key role to play in initiating discussions about sex and sexual difficulties with their patients. OBJECTIVE This article encourages GPs to take the lead in initiating a conversation about sex and sexual difficulties with their patients by taking a brief sexual history as a routine part of a medical history. If any sexual concerns are identified, a longer appointment can be arranged for a detailed history and examination, and to discuss treatment options, including referral. DISCUSSION Sexual difficulties are common and can affect a patient's quality of life. There is a high risk of sexual difficulties arising from illness, medication, and personal and relationship difficulties. Erectile dysfunction is particularly important to identify as it is a predictor of cardiovascular and other microvascular disease.
Background Major depressive disorder (MDD) in children (5-12 years of age) is a confronting and serious psychiatric illness. MDD has significant ramifications for the psychosocial development of the child, yet it remains under-recognised and undertreated. General practice is where these children and their parents will first present. Objective The aim of this article is to provide general practitioners (GPs) with a framework for considering MDD in a child and recommendations for treatment. Discussion Children with MDD have the same core features as adolescents and adults, taking into account the child's capacities for cognition and language, and developmental stage. Earlier onset of illness is associated with poorer outcomes and greater psychiatric morbidity persisting into adulthood. MDD is more common than anticipated, and should be considered for any child presenting with depressive symptoms and/or impaired psychosocial functioning. Despite limited evidence, numerous interventions exist that will, ideally, significantly affect the child's developmental trajectory. GPs are in an important position to initiate these interventions.
A man of Indian descent, 46 years of age, underwent a renal transplant two years ago for lupus nephritis. Aside from systemic lupus erythematosus, the patient had no other medical comorbidities. Immunosuppressive therapy included azathioprine 50 mg twice daily, tacrolimus 1 mg twice daily and prednisolone 5 mg daily. A 2 mm pigmented macule on his right sole was detected during a routine skin check (Figure 1). The pigmented lesion had not been noted previously. On examination with the naked eye, the lesion was unusual as it was darkly pigmented. Dermoscopy revealed a parallel ridge pattern with diffuse varying pigment and no involvement of furrows (Figure 2).
BackgroundData 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.ObjectivesThis paper provides an overview of data linkage and its relevance to general practice research.DiscussionData linkage enables large-scale studies of whole populations across the healthcare system. Data linkage has been used for studies of health service outcomes and use, epidemiology, and needs analysis. In Australia, there is growing interest in the potential to link data from general practice to other healthcare datasets. This can be achieved through access to Medicare data (Medicare Benefits Schedule and Pharmaceutical Benefits Scheme data) or potentially using data extraction tools to obtain more detailed clinical general practice data. In this article, we discuss issues that relate to privacy and ethical use of data in linkage studies, and provide examples of the types of research performed using this methodological approach nationally and internationally.
Background Injury to the tarsometatarsal joint is a relatively rare occurrence that is commonly missed, leading to debilitating outcomes. For this reason, it is considered a red flag in general practice.Objective This article reviews the current literature on tarsometatarsal injuries and describes clinical assessment, imaging and management.Discussion Lisfranc injuries refer to the displacement of the metatarsals from the tarsus, with special attention placed on the second tarsometatarsal joint and Lisfranc ligament. These injuries can occur in numerous circumstances, such as motor vehicle accidents, crush injuries and falls. Indirect mechanisms include axial force through the foot or twisting on a plantar flexed foot. Suggestive examination signs include plantar ecchymosis, mid-foot pain and positive findings in the provocative tests described in the article. Weight-bearing radiographs are vital for diagnosis. Correct and prompt management is key to avoiding posttraumatic arthritis, a devastating but common complication of Lisfranc injuries.
BackgroundThe increasing number of people reaching their 80s and 90s has triggered multidisciplinary consideration of how to address and capitalise on the longevity phenomenon.ObjectiveThe aim of this article is to provide an overview of ways in which clinicians can work with older patients to optimise their health and wellbeing during the later years of life.DiscussionOld age need not be burdensome to individuals or society. There is strong evidence to support the management of many chronic diseases presenting in - or extending into - old age. General practice will need to adapt to the demographic challenges of an ageing population by targeting conditions that impede people from contributing to family and societal life. General practitioners (GPs) will also need to adapt to the changing expectations of, and from, older patients across the upcoming generations.
BACKGROUNDObesity management in general practice sometimes involves referral of patients for bariatric surgery. Integral to the success of long-term weight loss maintenance is supporting the patient's psychological, nutritional and exercise needs.OBJECTIVEThis article is written to equip general practitioners (GPs) to manage the comprehensive needs, before and after bariatric surgery, of patients who are obese.DISCUSSIONThe number of patients undergoing bariatric surgery in Australia has increased significantly in the past few years. Pre-operative and postoperative management of this intervention presents a challenge for GPs. In this article we provide guidance around psychological, nutritional and exercise interventions, to equip GPs in managing patients who are obese. Access to allied health providers is not always available for patients, so this article is co-written with allied health colleagues who share their expertise as a resource for GPs.
Nasal obstruction may be acute or chronic and is a manifestation of a wide range of disease processes, most of which are managed by the GP. In patients with persistent nasal obstruction and in those with structural abnormalities, specialist referral is warranted.
BACKGROUND Cardiovascular disease (CVD) is a major cause of death in Australia. Electronic medical record (EMR)-based clinical decision support (CDS) tools have the potential to support absolute CVD risk (ACVDR) evaluation and management. The objective of this study was to test the acceptability and feasibility of the Treat to Target CVD (T3CVD), an EMR-based CDS tool, for the evaluation of ACVDR in general practice. METHODS Five general practitioners (GPs) piloted the T3CVD tool in their clinic. Interviews with the clinicians explored the acceptability and feasibility of the T3CVD tool. RESULTS The T3CVD tool was acceptable and, in the small pilot, was shown to have the capacity to support GPs in ACVDR assessment and management, and to encourage patient participation and motivation. Technical and structural factors important to ensure feasibility of the tool were identified. DISCUSSION With further development, the T3CVD tool has the potential to improve ACVDR assessment and management in primary care.
BACKGROUNDProcedural 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.METHODSA cross-sectional analysis of a cohort study of registrars' consultations between 2010 and 2016 was undertaken. Registrars record 60 consecutive consultations during each six-month training term. The outcome was any procedure performed.RESULTSIn 182,782 consultations, 19,411 procedures were performed. Procedures (except Papanicolaou [Pap] tests) were performed more often in rural than urban areas. Registrars commonly sought help from supervisors for more complex procedures. The majority of procedures recommended as essential in registrar training were infrequently performed.DISCUSSIONRegistrars have low exposure to many relevant clinical procedures. There may be a need for greater use of laboratory-based training and/or to review the expectations of the scope of procedural skills in general practice.
