Assessing and treating functional disorders

Functional disorders and medically unexplained symptoms: assessment and treatment. Per Fink and Marianne Rosendal, editors. Aarhus, Denmark: Aarhus University Press, 2015 (258 pages). ISBN 9788771248517.

The Research Clinic for Functional Disorders and Psychosomatics at Aarhus University Hospital in Denmark is the background for this book and its authors. This setting differs from the workplace of most Australian doctors, but many of the challenges are the same. Functional disorders are defined as “physical symptoms that cannot be attributed to any known, well defined, physical or psychiatric disorder”. “Medically unexplained symptoms, “bodily distress disorder or syndrome and health anxiety” are also useful descriptions for some patients.

The book covers the historical and cultural background, prevalence, diagnosis and classification of functional disorders. Some of this is rather Eurocentric. Theories of causation and contributing factors, including the doctor’s role, will be familiar to many readers. The chapter on patients’ symptom perception and illness belief is short but helpful.

Of most interest, but perhaps of less practical use, is the treatment plan used in this clinic. There is a general outline of familiar treatment options, including cognitive behavioural therapy and a supportive relationship with the general practitioner. The book describes the concept of stepped care, moving from the first step in primary care of normalisation and empowerment for mild symptoms, escalating to more specialised and multidisciplinary treatment for patients with severe, disabling symptoms. The second half of the book describes a primary assessment and treatment program, TERM, which includes understanding (taking a full history of symptoms and background), acknowledgement and feedback, negotiating a new or modified model of understanding, summarising, and planning follow-up.

If your practice has a significant number of patients who have medically unexplained symptoms, you will find this a useful guide to a more structured approach to helping them. Whether you have the time to carry through the suggestions in a busy general practice or a hospital setting may be more challenging.

Socio-demographic and structural barriers to being tested for chlamydia in general practice

General practice is at the forefront of health care in Australia, with more than 85% of the Australian population consulting a general practitioner each year.1 Preventive health care is an important activity in general practice, and includes the prevention of illness, the early detection of infection or disease, and the promotion and maintenance of health.2 While prevention is key to Australia’s future health, it is also critical in redressing the health disparities experienced by disadvantaged and vulnerable populations.

Chlamydia screening is a key preventive care activity for young Australian adults. Guidelines recommend that sexually active men and women aged 15–29 years have an annual chlamydia test,2 but less than 10% of this age group are screened each year in general practice.3 There are well documented barriers to the uptake of chlamydia screening, from the perspective of both the GP and the patient. For GPs, these barriers include time, lack of awareness or knowledge about chlamydia, lack of support for partner notification, and concern about embarrassing their patient.4,5 For patients, barriers include the cost of the GP consultation and the chlamydia test, availability of transport to the clinic, lack of knowledge about the need for testing, the location of the pathology collection site, embarrassment or unease about providing a specimen, and, for those living in rural and remote areas of Australia, fears about confidentiality, the lack of female GPs, and health care availability.6–12

The Australian Government funded a chlamydia screening trial in 2009 to determine whether annual chlamydia testing in general practice for 16–29-year-old men and women would reduce the population burden of chlamydia.13 As part of this ongoing trial, clinics in the intervention group have provided a multifaceted intervention designed to facilitate increased chlamydia testing.

We found in an earlier study that not all patients will follow through and have a chlamydia test when a GP requests one.14 Our trial provided the opportunity to investigate factors associated with not having a test after it has been requested by a GP. Further, our findings can be extrapolated to other preventive health activities in general practice where tests are requested.

Methods

Setting

The Australian Chlamydia Control Effectiveness Pilot (ACCEPt) is a cluster randomised controlled trial of a chlamydia testing intervention in general practice that commenced in mid-2010 and will be completed in late 2015. All 134 GP clinics in 54 rural and regional towns in Victoria (18 towns), New South Wales (21), South Australia (four) and Queensland (11) were recruited for the trial. A further eight clinics in metropolitan Melbourne were also recruited, for a total of 142 clinics. To be eligible for inclusion in the trial, towns had to have a minimum population of 500 people aged 16–29 years (2006 census) and fewer than seven clinics. Towns were excluded if a military base, university or mine was nearby, or if it was a tourist town. A list for each state was drawn up, and towns randomly selected until the required sample size was obtained. More than 90% of invited clinics agreed to participate. Towns were randomised to either a chlamydia testing intervention group or to a control group. Clinics in the intervention group were asked to target 16–29-year-old men and women for annual testing; they received a multifactorial intervention that included audit and feedback on their chlamydia testing rates, and incentive payments for each chlamydia test requested. Control clinics were requested to continue usual chlamydia control practices.

Data collection

A data extraction tool (GRHANITE) was installed on computers in 122 of the 142 participating clinics. Reasons for not being able to install the tool included the clinic not having a computer (two clinics), non-compatible medical records software (12 clinics) and refusal by the clinic (six clinics). This tool extracts de-identified patient consultation and chlamydia testing data on a weekly basis from the patient medical records database.15 Compatible medical records software includes Medical Director, Best Practice, GENIE, Zedmed, Medtech 32, Communicare, SHIP and practiX. Data included in the analysis were patient age and sex, clinic postcode, chlamydia test request (yes v no) and chlamydia test result (positive v negative v test not done). Additional clinic-specific data were obtained, such as whether the clinic bulk-billed consultations (a payment option in Australia: the doctor does not charge the patient for the consultation but is instead reimbursed directly by Medicare) and whether pathology or specimen collection was available on site. The socio-economic profile of the geographical location of each clinic was obtained by linking their postcodes with the Australian Bureau of Statistics’ 2011 Socio-Economic Indexes for Area–Index of Relative Socio-economic Disadvantage (SEIFA-IRSD).16 The IRSD scores areas according to relative disadvantage, ranging from 600 (most disadvantaged) to 1200 (least disadvantaged). The geographical location of the clinic was also classified according to rurality according to the 2007 Australian Standard Geographical Classification System–Remoteness Area (ASGC-RA).17 The ASCG-RA categorises areas according to their physical distance from urban centres (ie, access to goods and services). Its categories, in order of increasing remoteness, are major cities, inner regional, outer regional, remote, and very remote. No participating clinic was in the very remote category. For each clinic postcode, the proportion of the population with Aboriginal and/or Torres Strait Islander background was obtained. Chlamydia prevalence is higher among Aboriginal people, and it is important to determine whether there are any barriers to their having a test when requested by a GP.18

Data analysis

All chlamydia test requests were extracted for the period 1 January 2013 – 31 December 2013. The primary outcome for analysis was defined as “no test conducted” following a GP request. Factors associated with this outcome were explored using logistic regression; univariate and multivariate odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. All variables were included in the multivariate analysis. Effect modification was explored by fitting interaction terms to the model. Our main analysis was restricted to clinics participating in the intervention arm of the trial because of the availability of data. A total of 63 of 70 intervention clinics provided data for this analysis. We were able to investigate any potential selection bias by comparing the proportions of no test outcomes for intervention and control clinics. All analyses were performed in Stata 13 (StataCorp) and were adjusted for intracluster correlation at the clinic level. IRSD scores were categorised as quintiles for ease of interpretation and analysed as a linear variable, using the least disadvantaged category as reference. Age was categorised in bands (16–19 years, 20–24 years, 25–29 years).

Ethics approval

ACCEPt received ethics approval from the Royal Australian College of General Practitioners Ethics Committee (NREEC reference number 09/019).

Results

During the study period, the overall annual testing rate of 16–29-year-old men and women in the 63 intervention clinics was 19.2% (95% CI, 16.8–21.8%). A total of 13 225 chlamydia tests were requested; 9712 (73%) were for women. Overall, 29% of chlamydia test requests were for patients aged 16–19 years; 21% were requested by clinics in metropolitan Melbourne, 55% by inner regional clinics, 22% by outer regional clinics, and 2% by clinics in remote locations. About one-third of clinics (31%) provided bulk-billing services for students and young adults; 92% provided on-site specimen collection for pathology (Box).

No test was conducted for 2545 of the requests (19.2%; 95% CI, 16.5–22.3%). Univariate analysis indicated that the odds that no test was conducted were higher for men, those aged 16–19 years, and those living in areas of higher socio-economic disadvantage. Multivariate analysis indicated that the odds of no test being conducted were higher for men (adjusted OR [aOR], 1.4; 95% CI, 1.3–1.6), those aged 16–19 years (aOR, 1.3; 95% CI, 1.1–1.4), those living in areas of greater socio-economic disadvantage (aOR, 1.2; 95% CI, 1.1–1.4 for each additional quintile of Index of Relative Socio-economic Disadvantage), and those attending clinics without on-site pathology collection (aOR, 1.4; 95% CI, 1.0–1.9). The geographical location of the clinic, the availability of bulk-billing services, and the proportion of the population who identified as Aboriginal and/or Torres Strait Islander were not associated with the likelihood of a test not being done. No significant interactions between variables were detected.

Assessment of selection bias

During the study period, the overall annual testing rate in 59 control clinics was 10.9% (95% CI, 9.4–12.8%). A total of 7148 chlamydia tests were requested; no test was conducted in 1219 instances (17.1%; 95% CI, 12.9–22.2%). There was no difference between intervention and control clinics in the proportion of instances where no test was conducted (OR [intervention v control clinics], 1.2; 95% CI, 0.8–1.7; P = 0.42). As for the intervention clinics, univariate analysis indicated that the odds of a test not being conducted were greater for men (OR, 1.2; 95% CI, 1.1–1.4) and those aged 16–19 years (OR, 1.3; 95% CI, 1.1–1.5).

Discussion

We found that about one in five young people for whom chlamydia tests were requested by a GP did not submit a specimen. Men, people aged 16–19 years, those living in areas of greater socio-economic disadvantage, and those attending clinics without on-site pathology collection were less likely to follow through and be tested for chlamydia after a GP request. It is important to note that lower age and socio-economic disadvantage are key risk factors for chlamydia,20 highlighting how vital it is that clinics establish systems which ensure that tests ordered by GPs are actually undertaken.

We found that men were more likely to not undertake a requested test. Qualitative research has provided some insight into possible reasons for this. An evaluation of a peer-led intervention in the United Kingdom that aimed to increase chlamydia screening found that embarrassment was a key issue deterring young men from screening tests, whereas women were more open and accepting.21 Another UK study found that men’s attitudes to chlamydia screening were affected by a lack of knowledge and social embarrassment about chlamydia, a reluctance to seek medical help, a perception that chlamydia was a “women’s disease”, and indifference to health promotion campaigns.22

We found that those aged 16–19 years were less likely to undergo a test requested by a GP. It is possible that concern about confidentiality and privacy in general practice may have deterred some from chlamydia screening.10 Young people are also less likely to undergo annual health checks or to seek health information,23 and they express uncertainty or misconceptions about what the test entails.24 It has been argued that simply raising awareness about the risk of chlamydia may not increase testing rates, and that providing reassurance of non-infection may be more productive.25

We found that the odds of not undertaking a requested test rose with increasing levels of socio-economic disadvantage. This is consistent with an earlier study that found that those living in disadvantaged areas in Australia had lower chlamydia testing rates.26 This is a concern because socio-economic disadvantage is a risk factor for chlamydia infection,18 so it is vital that barriers to chlamydia testing are minimised in these areas. We found that the availability of bulk-billing for the consultation was not an important deterrent. However, we do not have information about whether the cost of the test was also bulk-billed, and it is possible that lack of knowledge about its cost may have deterred some patients from having the test. Qualitative research is needed to examine this possibility.

We found that the odds of not undertaking a test were 40% higher in clinics without on-site pathology collection. Chlamydia testing can be stressful for some patients, and any inconvenience, such as having to leave the clinic to attend an off-site pathology collection centre, will deter patients from following through with a test, especially if the testing centre is not nearby. Most pathology providers in Australia offer a courier service; if patients were able to leave self-collected specimens, such as urine or vaginal swabs, at a clinic, these could be collected by the provider, potentially increasing the uptake of testing.

A number of limitations must be considered when interpreting our results. Firstly, clinics were not randomly sampled for participation in the screening trial; as a result, our results may be subject to selection bias. However, this is unlikely to be important, as more than 90% of clinics agreed to participate, our analysis accounted for intracluster correlation within clinics, and we found no differences in results between intervention and control clinics. Secondly, more than 80% of our clinics were in rural areas, so that it may not be possible to generalise our results to all Australian clinics. Thirdly, data were unavailable for seven of the intervention clinics (10%) because we were unable to install our data extraction tool on a clinic computer. Fourthly, we were unable to assess other barriers to testing, such as the physical layout of the clinic, the location of a toilet, and the availability of local transport. Our analysis was also restricted to summary measures of bulk-billing and pathology collection at the clinic. It is possible that bulk-billing at some clinics may be at the discretion of the doctor, and some doctors may be willing to allow a patient to leave a specimen for collection if on-site pathology services are not available. We were also unable to assess the reason for test requests and whether there was any difference in the failure to test between those who were symptomatic or asymptomatic at the time of the request. Finally, it is possible that there were errors in our data extraction, and that not all chlamydia test requests and results were extracted. However, this problem is unlikely to be significant, because we also collected chlamydia testing data from pathology providers to validate the data extracted for each clinic.

The strengths of our study included its large sample size. Further, more than 90% of clinics agreed to participate, we adjusted our analysis for intracluster correlation within clinics, and we investigated area-level, clinic-level and patient-level factors. We believe our results can be extrapolated to other preventive health activities targeting this age group in general practice.

Conclusions

We found that men, those aged 16–19 years, those living in areas of increasing socio-economic disadvantage and those attending clinics without on-site pathology collection services were less likely to be tested for chlamydia following a GP request. Qualitative research is needed to understand why these individuals are not tested. This is important information for health service delivery in general practice, and highlights the need for clinics to develop systems which ensure that men, younger people and those living in socio-economic disadvantaged areas have a test when requested by their GP.

Box –
Factors associated with a patient not having a test for chlamydia following a request by a general practitioner

Characteristic	No tests done (total test requests)	No tests done as proportion of test requests	Univariate OR (95% CI)	P	Multivariate OR (95% CI)*	P

Total	2545 (13 255)	19.3%
Sex
Women	1738 (9712)	17.9%	1		1
Men	816 (3513)	23.2%	1.4 (1.2–1.6)	< 0.01	1.4 (1.3–1.6)	< 0.01
Age
16–19 years	805 (3807)	21.1%	1.2 (1.1–1.4)	< 0.01	1.3 (1.1–1.4)	< 0.01
20–24 years	1072 (5677)	18.9%	1.1 (0.9–1.2)	0.30	1.1 (0.9–1.2)	0.37
25–29 years	668 (3741)	17.9%	1		1
Clinic location^†
Major cities	559 (2757)	20.3%	1		1
Inner regional	1349 (7322)	18.4%	0.9 (0.4–1.8)	0.74	0.6 (0.3–1.3)	0.23
Outer regional	572 (2871)	19.9%	1.0 (0.5–2.0)	0.95	0.7 (0.3–1.7)	0.47
Remote	65 (275)	23.6%	1.2 (0.5–3.0)	0.67	0.8 (0.4–1.9)	0.65
Index of Relative Socio-economic Disadvantage^‡	NA	NA	1.2 (1.1–1.3)	< 0.01	1.2 (1.1–1.4)	0.01
Bulk-billing
Yes	1726 (9141)	18.9%	1		1
No	819 (4084)	20.1%	0.9 (0.6–1.5)	0.76	1.2 (0.8–1.8)	0.36
On-site pathology collection
Yes	2292 (1219)2	18.8%	1		1
No	253 (1033)	24.5%	1.4 (1.0–2.0)	0.08	1.4 (1.0–1.9)	0.05
Aboriginal and/or Torres Strait Islander^§
< 0.6%	573 (3415)	16.8%	1		1
0.6%–1.1%	940 (4178)	22.5%	1.4 (0.9–2.2)	0.10	1.4 (0.8–2.4)	0.24
1.2%–2.5%	383 (2326)	16.5%	0.9 (0.7–1.4)	0.91	1.1 (0.6–1.8)	0.99
≥ 2.6%	649 (3306)	19.6%	1.2 (0.9–1.6)	0.19	1.1 (0.6–1.8)	0.81

NA = not applicable; OR = odds ratio. * Adjusted for all variables in the table. † Australian Standard Geographical Classification System – Remoteness Area.17 ‡ IRSD score was categorised into quintiles and analysed as a linear variable using the least disadvantaged area as reference. Odds ratio is for the change in the odds of no test being performed for each additional increase in IRSD quintile. § Proportion of population identifying as Aboriginal and/or Torres Strait Islander; based on reference 19.

Shiitake dermatitis: the tale of an under-recognised, undercooked fungus

Clinical records

Case 1

A 55-year-old man with no medical history or allergies presented in May 2015 with a widespread, pruritic, whiplash-like rash (Figure 1). On examination, multiple erythematous papules in a linear distribution, corresponding to areas of excoriation, were noted on his trunk, limbs, forehead and scalp. The rash had developed 12 hours after a meal containing fresh shiitake mushrooms. There were no associated systemic symptoms and the patient’s condition did not improve with topical administration of betamethasone dipropionate 0.05%. Based on dietary history and the characteristic appearance of the rash, a diagnosis of shiitake dermatitis was made. The rash resolved in 3 weeks without further treatment. The patient experienced a recurrence 5 months later, after eating another meal containing shiitake mushrooms.

Case 2

A 30-year-old man with no comorbidities or allergies presented in March 2015 with a 2-day history of a striking, linear, erythematous eruption (Figure 2). He was systemically well, but reported associated perioral tingling and pharyngitis, which were unresponsive to 10 mg oral cetirizine. Examination revealed linear groupings of papules on an erythematous urticated base on his forehead and trunk. Despite denying pruritus or excoriations, relative sparing of the central back (out of the patient’s reach) was noted. Further questioning revealed ingestion of lightly cooked shiitake mushrooms the night before the onset of symptoms. No relatives who had eaten the same meal were affected. The patient was diagnosed with shiitake dermatitis, and the rash resolved completely without treatment.

Case 3

A 44-year-old man presented in August 2015 with a 2-day history of a flagellate erythematous rash (Figure 3). His past history included ischaemic heart disease, hypercholesterolaemia and rosacea. He had eaten raw shiitake mushrooms while cooking, and woke the next morning with a rash on his arms. Despite treatment with 25 mg oral prednisolone and topical betamethasone valerate 0.02%, prescribed by his general practitioner, the rash rapidly extended to his trunk, shins and scalp. His full blood count, C-reactive protein level and biochemistry results were unremarkable. A diagnosis of shiitake dermatitis was made. The patient’s wife, with whom he had shared the cooked meal, was asymptomatic, and the patient had previously eaten cooked shiitake without problems. Ten days later, the rash was resolving rapidly, with mild hyperpigmentation.

Shiitake mushrooms (Lentinus edodes) account for 20% of mushroom production worldwide1,2 and are the second most commonly eaten mushroom variety.1,3 Originally, most shiitake were log-grown in Japan. Since the late 1980s, most shiitake have been cultivated on a sawdust-based substrate in China.4,5 Shiitake are used in Asian medicine for their antihypertensive, anticarcinogenic and cholesterol-reducing qualities.1,5 Shiitake spores can cause IgE-mediated illness, such as hypersensitivity pneumonitis, asthma and allergic rhinitis.1,3,6 Shiitake can also cause contact urticaria, protein contact dermatitis and allergic contact dermatitis.1,3,6 In this article, we present the first three published cases of shiitake dermatitis in Australia. Systemic dermatitis caused by ingested allergens has also been reported with other foods, including spices, garlic, onions and root vegetables, metals, drugs, and preservatives.7,8

Shiitake dermatitis is also known as flagellate erythema, flagellate dermatitis and toxicodermia.3 It was first described in Japan in 1977, in Europe in 2006 and in the United States in 2010.1,2 Flagellate erythema occurs with all forms of shiitake — fresh, dried, powdered, boiled, baked, grilled and fried.2,5 It has been reported from adolescence to old age, and is more common in men.2

The highly distinctive rash develops following the ingestion of undercooked shiitake mushrooms by susceptible individuals. Onset usually occurs 12–48 hours after intake, although the reported range is 2 hours to 5 days.1 Intensely pruritic, linear, erythematous papules and petechiae develop on the trunk, limbs, head and neck,2 sparing the oral mucosa. The flagellate morphology is attributed to the Koebner phenomenon.2,3 There may be associated local oedema, fever, malaise, lip tingling, dysphagia and diarrhoea.1,9,10 Up to 47% of patients display ultraviolet A photosensitivity and photo-aggravation.3,9 Differential diagnoses include the flagellate rash associated with bleomycin, dermatomyositis, adult-onset Still disease, and HIV with hypereosinophilic syndrome.11

Lentinan, a thermolabile polysaccharide component of shiitake mushrooms, is the cause of shiitake dermatitis.1–3,5,9 Lentinan undergoes a conformational change at 130–145°C, so it is recommended that shiitake are cooked at temperatures of 150°C or greater to prevent toxicity.10 The pathogenesis remains unclear, but frequent case reports of single patients who had take part in shared meals and the delayed time course support the likelihood of an allergic reaction,2,10 with a possible role for exacerbating cofactors, such as use of angiotensin-converting enzyme inhibitors or diuretics, and exposure to ultraviolet A light.1,9 A trial of 519 patients in Japan who received intravenous lentinan chemotherapy yielded nine cases of flagellate erythema; extrapolating from these data, up to 2% of the population will be vulnerable to shiitake dermatitis.1,2

A case of shiitake dermatitis following ingestion of log-grown shiitake was recently reported in a patient who had previously tolerated substrate-grown shiitake from China.5 The authors of this report proposed that shiitake dermatitis may occur only with log-grown mushrooms. This hypothesis is supported by the low incidence of shiitake dermatitis in China, where the shiitake are substrate-grown, and the lower rates in Japan since 1992, when local production switched to substrate-grown mushrooms and the Japanese government began importing substrate-grown shiitake from China.4,5 Most cases in Japan were reported before 1998,9 typically during the harvest season for log-grown shiitake mushrooms.2 In Australia, shiitake are produced by both cultivation methods, and some shiitake are imported from China.12

The diagnosis is made clinically, and may be confirmed by oral re-challenge. Histopathological testing of skin biopsy specimens does not provide specific diagnostic information; it generally reveals elongation of rete ridges, spongiosis, degenerating keratinocytes, dermal oedema, and a superficial and perivascular lymphocytic infiltration with eosinophils and neutrophils.1,2 Prick and patch tests conducted by authors of previously published case reports have yielded conflicting results.1,2,10 Positive patch test results have also been obtained in control subjects, further limiting their usefulness in flagellate erythema.2,10

No treatments have been shown to be effective for shiitake dermatitis, although oral antihistamines and topical and oral corticosteroids are often prescribed. Given the high reported rate of ultraviolet A photosensitivity, patients should be given guidance on careful photoprotection.1 The prognosis is excellent, with improvement from 2 days and resolution by 3 weeks.1,2

In Australia, only four confirmed cases and one possible case of shiitake dermatitis were reported in 11 years (Appendix); these were reported to the NSW Poisons Information Centre between January 2004 and April 2015. No cases have been reported to the poisons information centres in Western Australia, Victoria and Queensland. Given our experience of three cases at a tertiary hospital within 12 months, and the prevalence of shiitake consumption in Australia, we believe that shiitake dermatitis is under-recognised. The mushroom industry heavily endorses the health benefits of shiitake as a low kilojoule source of dietary fibre, protein, vitamins, antioxidants and minerals. Considering the availability of shiitake-based health supplements on the internet,1 the popularity of Asian cuisine, and the production of log-grown shiitake in Australia today,12 we anticipate an increasing incidence of shiitake dermatitis. Documenting the preparation temperature, cultivation method and source of the shiitake mushrooms in future cases may help elucidate the pathogenesis.

Lessons from practice

Shiitake dermatitis is probably under-recognised and under-reported in Australia
The diagnosis is made clinically, based on dietary history and a characteristic erythematous flagellate rash
The prognosis is excellent, but patients should be advised to avoid shiitake or to ensure it has been cooked at temperatures of 150°C or greater to prevent further episodes
Primary care practitioners, such as general practitioners and emergency physicians, should be aware of the diagnosis to avoid unnecessary investigations and treatments

Figure 1 –

Figure 1: Widespread, characteristic flagellate erythema of shiitake dermatitis in a 55-year-old man

Figure 2 –

Figure 2: Linear grouped papules on an erythematous urticated base in a 30-year-old man with shiitake dermatitis

Figure 3 –

Figure 3: Intensely pruritic, linear, erythematous rash in a 44-year-old man with shiitake dermatitis

[Correspondence] Call to duty revisited

As longserving surgeons in the Veterans Health Administration (VHA) system, we found the Editorial1 about the VHA both disturbing and misleading. In view of the fact that the UK does not have a specific agency devoted to veterans, this critique of the VHA is unwarranted and non-specific. The Editorial is another gratuitous example of piling on criticism in response to news of admittedly egregious administrative wrongdoing in the misreporting of waiting times for access to primary care in the VHA health-care system.

Do you know what you don’t know? Want to find out?

Doc Rob is a Sunshine Coast GP who blogs on FOAM 4GP (Free Open Access Medical Education for General Practice). If you work in healthcare and have a blog topic you would like to write for doctorportal, please get in touch.

I asked an amazingly brilliant GP, who has been one of my long time mentors, why he had had a few patients with a TSH <0.05 for many years. He replied that he titrated to T3/T4 levels as he always does. He was horrified when I showed him that best practice is to titrate to TSH not to T3/T4 and that his patients were possibly at increased health risks. He couldn’t believe it! How could he have been practicing for such a long time and never come across this!! In reality, his patients felt fine, and therefore there was no opportunity for feedback. And this doctor is brilliant! It is SO easy to keep doing what we have always done and not know if it is best practice!

I remember being told at the first day of medical school that 50% of what we will be taught will be shown to be wrong. How do we know which 50% to forget?!

When we are students and trainees we have someone looking over our shoulder gently nudging our clinical practice towards best practice. When we finish training however, and we are out on our lonesome. How do we know if we lapse into ‘not the best practice’ or when the evidence base shifts away from our usual practice (I wish it would stop doing that!)?

So! I just casually asked 2500 Australian GPs and GP registrars what they wished other doctors knew – or could be better at – on a forum called GPDU (GPs down under – closed group on Facebook). This was open slather – suggestions for patients, students, junior doctors, and all specialist groups. I almost broke Facebook with the MASSIVE response.

So before you have a look at the list I want to give one piece of advice. We are all human, we all make mistakes, we are all learning, and I would rather see the doctor who accepts new practices and adapts/changes/learns.

Disclaimer: I am NOT stating that you should do all of these things. These are all things to make you stop, think, and if you are uncertain, go and look up the evidence yourself. The responsibility you take for your own clinical practice is your own and you treat your own patients.

* Some of these are contentious – but that is part of the fun of medicine. Let’s debate and discuss! I will put up the links to evidence where I can find it.

** I have put in brackets the amount of ‘likes’ they received. Think of it as a guide as to how strongly everyone felt about a particular issue. Not as a guide to whether one thing is more important than another.

Top 10 “Liked” suggestions which we should change:

Sending the “tears and smears” to the nice lady doctor (49) – Aus Doc – Gender in general practice
Prescribing duromine for weight loss on every overweight patient (39) – FOAM4GP debate
Using urine bags to collect urine specimens (36) – J Paed 2000 – (62% contamination rate!)
Prescribing benzodiazepines long term for ‘anxiety’ or ‘insomnia’ (36) – RACGP Benzodiazepines guideline
Performing quantitative bHCGs on routine pregnancy bloods (36) – Womens Hospital Shared care Guidelines
Suggesting a previous doctor’s management was inadequate without knowing the circumstances (35) – It is not required for patient care. Can provide feedback to the previous doctor if required – Journal of General Internal Medicine 2013, Communication and Courtesy MJA
Not prescribing a spacer with inhalers (30) – Asthma Handbook
Not doing asthma action plans (30) – Asthma Handbook
Commencing LABA as first line for asthma (30) – Asthma Handbook
Ordering Herpes Simplex Serology (30) – I’m still trying to brainstorm a time when this would actually be helpful!? – KevinMD
Not warning women about the transvaginal US when it is required (28) – Patient information sheet
Performing hormone studies (FSH/LH/E2/Prog) to diagnose menopause or on every perimenopausal woman (20) – Australian Menopause Society diagnosis guidelines
Doing an ESR with every FBE (19) – Never indicated to do ‘routinely’ – FOAM4GP ESR & CRP
Acquiescing to requests for reverse T3, MTHFR etc. (tests without strong evidence base) (23) – Basic rule – don’t order a test you don’t know how to interpret with an evidence basis. Suggest they go back to the requesting practitioner. Screening tests of unproven benefit RACGP,
Not giving patients written advice on what they should do for their own care (8) – NHMRC – Communicating with patients
Checking lipids every year for primary prevention when low risk (30) – RACGP Red book (recommends 5yrly)
Prescribing sleeping tablets before sleep hygiene (26) – Sleep Hygiene Informed online. Can suggest always use non-pharm approaches first
Ordering TSH as a general screening tests on “check up” bloods (5) – TSH ordering guidelines – NPS
Ordering TFTs and not TSH in a ‘low suspicion’ or screening setting (3) – Though some labs do this anyway –Medicare will actually not bulk bill T3/T4 unless TSH is abnormal or other criteria is met – this is listed at the bottom of the page (1). – T SH ordering guidelines
Getting another doctor to “removal of stitches” after a procedure (9) – After care cannot be billed a second time.MBS guideline
Radiologists changing the “due date” on pregnancy scans without explaining why (17) – Recommendations at – 7.2 of the shared care Mater guidelines
Plain back xray in the absence of red flags (27) – WA Imaging guidelines
Sending women with breast lumps for US without clinical examination (8) – Breast symptom guidelines NHMRC
Antibiotics for abscesses and not incising when appropriate (12) – “Never let the sun set on undrained pus”WestJEM 2013
Not asking about migraine or DVT history when prescribing or re-prescribing COCP. Answers can change! (38) –Good general advice! History’s often change – Family Planning NSW
Antibiotics for painful teeth (13) – eTG has great freely accessible guideline on when to use ABs
Recommending OCP or POP as first line for contraception instead of LARCs. (25) – Sexual health and Family Planning Australia
Declining IUDs for nulliparous women (25) – They can be used simply and safely – Sexual health and Family Planning Australia
Continuing folic acid supplementation throughout entire pregnancy rather than just the first trimester (16) – They recommend for 1mth before conceiving and until week 12 unless there are other reasons- RANZCOG Vitamin and Mineral supplementation
Inappropriate prescribing of ABs eg. Augmentin for everything (24) – eTG recommended resource.
Prescribing COCP in patients with migraine with aura – WHO eligibility chart for contraception types
Doing chronic disease management plans and team care arrangements on patients who have another regular doctor (11) – Best performed by the patients regular doctor – CDM Point 1.8
Writing only minimal detail on a mental health care plan other than ‘depressed’ (11) – Templates for detail from RACGP
Ordering arbovirus or zoonosis tests just to ‘see if the patient has had them in the past’ (4) – Zoonoses – Tools for GP
Doing investigations which are not going to change management or provide prognostic information (10) –Testing times – RACGP
Referring a patient with PR bleeding for a colonoscopy without performing a PR exam (Pt’s have been seen who have had an anal cancer but were triaged low for colonoscopy because not checked) (7) – AFP 2010 – The bottom line
Prophylactic removal of moles because “the patient has a lot of them” (6) – Cancer.gov
Complaint of ‘smelly vaginal discharge’ – not looking, swabbing, examining – and prescribing random tinidazole or whatever (14) – STI guidelines Australia
Still performing DRE for prostate cancer screening (10) – Prostate.org – New guidelines 2016
Long time antibiotics for Lyme disease (10) – If the patient even has Lyme unless they recently returned from an endemic area. Current Government guideline.
Approaching every nursing home patient assuming they are deaf, demented, and unable to make decisions.(11) –Silver Book RACGP
Stopping or starting allopurinol during an acute gout flare (8) – BPAC NZ
Not considering ‘quick start’ contraception in sexually active women (12) – Family Planning Victoria – Great table. Helps prevent ‘surprise’ pregnancy.
Not recognising or diagnosing PCOS – Jean Hailes
Using flucloxacillin for preschoolers – Caused BIG debate. Apparently the children HATE the taste. Long debate about best practice vs reality. “Most ghastly tasting concoction ever created – Grandmother” – Entertaining blog from a grandmother. Netmums
Assuming heavy periods are ‘normal’ and an expected part of being a woman. Offering OCP or hysterectomy as the only treatment options. Treating with iron but not stopping the haemorrhage! (3) (13) – RANZCOG 2014
Fill in the appropriate forms for supporting patient travel schemes in your state (7) – Rural and regional National
Don’t order a battery of tests as a ‘check up’ (8) – Refer to RACGP Red book for appropriate follow up times
Treating “low serum iron” with iron supplements in normal ferritin etc. (3) – FOAM4GP While the Fe is hot!
Not registering your opioid requiring patients with relevant state body (11) – Eg QLD
Never stopping stuff! (eg Statins or PPIs) (15) – Deprescribing (NPS)
Ordering ANA’s in patients without high pre-test probability of rheumatoid disease (7) – Results are often confusing and unhelpful – RACGP ANA
Not avoiding opiates for non-cancer chronic pain at all costs! (6) – RACGP drugs of dependence
Prescribing medications (particularly specialists starting them) when they cannot be continued on the indication on the PBS (4) – PBS guidelines
Prescribing antidepressants as the first line treatment for mild/moderate depression (6) – Beyond Blue NHMRC Guidelines
Ordering a GCT instead of an OGTT in pregnant women (14) – RANZCOG
Not warning patients about possible out of pocket costs for some tests eg. Thrombophilia screen (if not fitting criteria) (6) – MBS
Continuing to use aspirin for primary prevention of cardiac disease (3) – MJA
Going on holidays without organising your chronic pain patients and drug addicted patients which you are managing are ‘handed over’ or appropriately supported (9) – Safe patient handover AMA
Recording allergies in the computer without stating what the issue was (3) – RACGP – Allergy? Adverse reaction? Intolerance?
Telling women to stop breastfeeding because of certain medications without checking or discussing with pharmacist (18) – LactMed
Telling patients to stop their high dose SSRI/SNRI without warning about side effects – SSRI discontinuation syndrome
Swabbing kids noses/throats for simple URTI and then treating with ABs if there is a bacteria there (7) –BroomeDocs
Performing xrays for low risk possible rib fractures (4) – AFP Thoracic imaging
Using Quetiapine for insomnia. Used off licence and don’t organise follow up (9) – NPS 2014
Performing a venesection for mildly elevated ferritins without haemochromatosis (4) – RACGP Elevated serum ferritin
Alprazolam. For anything really. (13) – There are much better options – Alprazolam AMA guidelines
Failing to recognise the possibility of an eating disorder (17) – RANZCP guidelines for eating disorders
Referring to a specialist colleague without an appropriate letter or work up. Gives GP’s a bad name (22) –FOAM4GP referral letter
Performing corticosteroid injections for tennis elbow (13) – MJA 2013
Doing an MRI of the knee for new minor knee pain without significant features or red flags (3) – WA imaging guidelines
Advising not to get sutures wet after a simple skin excision – BMJ 2006
Suggesting patients ‘swim in the salt water‘ with a wound – Expedition medicine, Scuba-doc
Starting beta blockers as first line for hypertension (7) – AHFoundation guidelines
Ordering exercise stress tests on intermediate or high risk patients instead of MPS / Stress Echo (3) –FOAM4GP Stress Test
Allowing chronic patients to think the solution to their pain is in a pill without addressing other lifestyle factorsand education (10) – SA Guidelines
Neglecting lifestyle measures for patients with chronic diseases (7) – SNAP RACGP
Patients admitted to nursing homes without discussion of resuscitation/AHDs, EPOA, wills etc. (17) – RACGP Silver Book
Putting tired middle aged men on DHEAs (1) – Evidence is not strong and evidence of harms – Mayoclinic
Pre travel consultations without discussing multiple issues other than just vaccinations. Eg. safe sex, sunburn, safety, insurances, consent, medical condition mmnt etc. (11) – RACGP Travel advice
Giving repeat courses of ABs for a ‘cough’ without considering other causes eg. cancer, GORD, ACE inhibitor (5) – MJA CICADA Guidelines 2010
Daily dressings of non-healing leg ulcers without further investigation or referral as appropriate (10) – Wound healing guidelines
Starting statins in mildly elevated cholesterol without offering lifestyle advice or assessing absolute CVD risk (6) – CVD Risk Calculator
Leaving people on antidepressants/antianxiety medication for years without considering ceasing (6) – Psych UK “Coming off antidepressants
Adding on BP medications in a patient with high BP without checking if they are actually taking their other medication (6) – Compliance check
Not discussing with terminal patients where they would like to die eg. Home/hospital – Centreforpallcare.or
Continuing to prescribe medications with brand names even though the patient gets generic anyway. Just confuses everyone (12) – NPS guideline
Failing to stop (or starting) HCT in a patient with gout (4) – EBM Consult
Giving B12 injections where the only indications were “fatigue” and the B12 was “a little low” (6) – Medscape 2009
Specialists asking a GP to ‘organise an MRI’ as an outpatient without realising this will cost the patient a large amount of money. Allied health referring to GP to get ‘an MRI’ because ‘your GP can get you one’ (4) – RACGP MRI guidelines
Not avoiding the triple whammy – ACE, NSAIDs, and loop diuretics (5) – Kills kidneys TGA
The use of depo-provera without considering other better options without unknown risks of bone density problems (7) – ACOG 2014
Not getting images from the hospital! Important clinically to be able to review images yourself (4) – Surely we can fix this soon!
Prescribing bisphosphonates for years without review or BMD or lifestyle modification (5) – Eg. BMD every 2 years after starting – RACGP Osteoporosis
Allowing a patients Hba1c to remain high for many years without trying to create an appropriate target and lowering (2) – BPAC NZ 2010

So there is the list. I certainly have changed a few things I do from the list. How did you go? Hopefully it was helpful!

Will repeat this again in the future and see if things change over time. In the meantime how can you help other doctors also?

Here is my suggestion:

Use this resource as printed out and left in a tea room as a conversation starter, use it in a teaching session with a registrar or medical student, or feed it to your dog (not sure how the last one will help other than maybe make you feel better!)

Give us some feedback – would love to know what people think. Let’s debate!

This blog was previously published on FOAM 4 GPs and has been republished with permission. If you work in healthcare and have a blog topic you would like to write for doctorportal, please get in touch.

Other doctorportal blogs

Warning over diabetic ketoacidosis after man’s death

GPs are being told to consider diabetic ketoacidosis after a man died less than 24 hours after presenting to his doctor.

According to the Victorian Coroner’s report, a 29-year-old male visited his GP complaining of increased urination, thirst and difficulty sleeping.

He had a fever of 38.6 with high blood pressure and the GP prescribed cephalexin antibiotics for a urinary tract infection.

A urine sample was taken and sent to pathology as well as requests for blood tests including full blood exam, LFT, TSH, urea and electrolytes and fasting blood glucose.

However the patient was found dead in his home at 9pm the following day. A taxi was booked at 5:30am that morning however he didn’t respond to the taxi’s arrival at between 7:40am and 8am.

The pathology report dated the day after testing found ketones and glucose in the urine sample.

The coroner found that the patient died from diabetic ketoacidosis. Post mortem toxicological analysis showed a glucose concentration of 45mmol/L, combined with raised acetone levels in the blood and vitreous. The coroner said this indicated that the man had died of undiagnosed diabetes.

The patient had reported considerable weight gain over the previous year, resulting in him weighing 122.9kg when he presented to his doctor. The GP concluded that the patient likely had diabetes and ranked the likelihood as Type 2 ahead of Type 1 diabetes. However he didn’t check the patient’s blood glucose at the time, instead referring him for fasting blood tests the next day.

It is noted in the coroner’s report that the GP was regretful that he didn’t perform a fingerprick test at the time of consultation and that it would have been the appropriate action.

The report stated that the doctor was under the impression that fasting blood tests was the most accurate way to diagnose diabetes. “(The doctor) did not consider that (the patient) was in any immediate danger from diabetes,” the report said.

CPD active learning module: Addressing the challenges in the fast moving field of endocrinology

The coroner recommended the following:

The Royal Australian College of General Practitioners provides a clinical update to GPs to highlight the importance of recognising hyperglycaemia and ketosis in adult diabetic patients, as an uncommon but potentially serious complication of type 2 diabetes, or indication of newly recognised adult-onset type 1 diabetes.
The Royal Australian College of General Practitioners advise GPs that although uncommon in adults and clinically subtle in its earliest states, evolving diabetic ketoacidosis may produce a dangerous metabolic decompensation and require escalation of care to a hospital setting for further assessment and management.

RACGP President Dr Frank R Jones told doctorportal: “The RACGP will certainly review and respond to the coroner’s recommendations regarding diabetic ketoacidosis (DKA) as published in the findings into the death of (the patient) and will communicate a clinical update to members.

“The RACGP does have some existing guidance on DKA in its resource General practice management of type 2 diabetes.”

Latest news:

Look no further than GPs for Medical Home

GPs already perform many of the functions of a Medical Home, and should be at the centre of any move to formalise such an arrangement in Australia, the AMA has said.

As Health Minister Sussan Ley contemplates the findings and recommendations of the primary health review led by former AMA President Dr Steve Hambleton, the AMA has issued a Position Statement advising that any proposal to adopt a Medical Home approach in Australia must have GPs at its core.

Internationally, the term Medical Home is used to refer to a model of primary care that is patient-centred, comprehensive, team-based, coordinated, accessible and focused on quality and safety.

AMA Vice President Dr Stephen Parnis said in Australia these attributes were already embodied in general practice.

“The concept of the Medical Home already exists in Australia, to some extent, in the form of a patient’s usual GP,” Dr Parnis said. “If there is to be a formalised Medical Home concept in Australia, it must be general practice. GPs are the only primary health practitioners with the skills and training to provide holistic care for patients.”

Evidence suggest patients with a usual GP or Medical Home have better health outcomes, and 93 per cent of Australians have a usual general practice, and 66 per cent have a family doctor.

Dr Parnis said the Medical Home concept had the potential to deliver improved support for GPs in providing well-coordinated and integrated multi-disciplinary care for patients with chronic and complex disease, and it made sense for this to be the focus of Government thinking on adopting the Medical Home idea in Australia.

“You can’t just transplant models of health care from other countries without acknowledgement of local conditions and what is already working well,” he said.

“Australia needs to build on what works, and ensure that a local version of the Medical Home is well-designed and relevant.”

The AMA said this should involve additional funding to enable GPs to deliver comprehensive and ongoing care, including patient education, improved coordination and targeting of services, and activity that does not require face-to-face contact.

Establishing a Medical Home arrangement in Australia was likely to involve formally linking a patient with their nominated GP or medical practice through registration, and the AMA said this should be voluntary for both patients and doctors.

In addition, the peak medical group said fee-for-service must remain the predominant funding mechanism for doctors, though it acknowledged that the Medical Home could also involve a blended funding model that rewarded the delivery of services over a period of time.

The AMA Position Statement on the Medical Home can be viewed at: position-statement/ama-position-statement-medical-home

Adrian Rollins

A survey of Sydney general practitioners’ management of patients with chronic hepatitis B

In Australia, the prevalence of chronic hepatitis B (CHB) infection has increased over the past decade, with an estimated 218 000 Australians living with the disease.1 The annual number of deaths attributable to CHB is also expected to rise from 450 in 2008 to 1550 in 2017.2 Cost-effective treatments to reduce morbidity and mortality are available;2–4 however, up to 44% of infected Australians remain undiagnosed1,5 and only 2%–13% of those infected are receiving adequate treatment.2,6

The highest prevalence of CHB in New South Wales is in the Sydney and South Western Sydney Local Health Districts (LHDs), with respective estimated prevalence rates of 1.67% and 1.61% (the NSW average is 1.11%).7 In these LHDs, a large proportion of the population was born in countries with an intermediate or high prevalence of CHB.8,9 To relieve the pressure on specialist liver services, the National Hepatitis B Strategy 2014–20175 recommends an increased role for general practitioners in the management of CHB. We therefore examined the CHB assessment and management practices of GPs in the two LHDs, and the confidence that these GPs have in different models of care.

Methods

We used a descriptive cross-sectional study design to survey GPs about case management. A questionnaire (Appendix) was developed by a steering group that included hepatologists, nurses, public health physicians, an infectious diseases physician and a GP. The survey also included a separate section on contact management; this is not discussed in this article.

Eligible GPs were those practising in Sydney LHD (SLHD) or South Western Sydney LHD (SWSLHD) who had had at least one patient aged 18 years or over who had been notified as having CHB to the Public Health Unit under the NSW Public Health Act 2010 between 1 June 2012 and 31 May 2013. A survey was posted to each GP, and those who had not returned it within 4 weeks received a telephone call and another copy of the survey. GPs were excluded if they no longer practised at the same location.

Returned surveys were coded and the data entered into Excel 2010 (Microsoft) and analysed with Excel 2010 (Microsoft), SAS Enterprise Guide 6.1 (SAS Institute) and Stata 10.0 (StataCorp). Blank responses were coded as “unknown”. Demographic information for all GPs in SLHD and SWSLHD was obtained from the Inner West Sydney and South Western Sydney Medicare Locals.

Human research ethics approval was granted by the SLHD Ethics Review Committee (RPAH Zone), protocol number X13-0035.

Results

Completed questionnaires were returned by 123 of 213 eligible GPs (57.7% response rate), with no statistically significant difference in response rate between SLHD and SWSLHD GPs (P = 0.41).

There were significant differences in sex, age distribution, and type of practice between the study participants and those of all GPs in SLHD and SWSLHD (Box 1). The average number of patients with CHB notified by responding GPs during the study period was 1.88, compared with 1.96 for non-responders (P = 0.73). Most GPs (97 of 123, 78.9%) estimated that they cared for 50 or fewer patients with CHB. GPs from SWSLHD were more likely than SLHD GPs to have cared for more than 50 patients with CHB (odds ratio [OR], 3.24; 95% CI, 1.08–9.68).

GPs were asked how confident they were about different aspects of CHB assessment and management (Box 2). GPs who reported that they were “not very” or “not at all” confident were more likely than GPs who were “very” or “reasonably confident” to have cared for 50 or fewer patients (OR, 1.26; 95% CI, 1.14–1.40).

Box 3 summarises responses by GPs who were asked how comfortable they would be managing a patient with CHB in a number of different scenarios. GPs who were at least reasonably confident without specialist or hepatitis nurse input were more likely than those who were not to have cared for more than 50 patients with CHB (OR, 4.68; 95% CI, 1.28–17.16).

Discussion

This is the largest survey of Australian GPs to have examined their CHB assessment and management practices, and their views about specific models of care. Our results have important implications for service development. We found that GPs were generally confident about diagnosing and managing CHB, and were most comfortable with a model of care that included an initial specialist review. However, a significant number of GPs were not confident about managing CHB, particularly without the support of a specialist. If there is to be a successful shift toward a CHB model of care in which primary health care plays an increased role,5 this problem will need to be addressed by policy makers and medical educators. A framework that provides GPs with the support and resources necessary for appropriate CHB management is needed.

Most GPs felt confident about CHB management, but it is notable that almost one-fifth were “not very” or “not at all” confident. These GPs were more likely to have had a lower CHB patient load, and may thus have had less experience in this area. Previous surveys of Australian GPs have identified knowledge gaps about different aspects of CHB management.8,10,11 Our findings are consistent with these reports, but also indicate that a supportive CHB model that enables GPs to easily access appropriate resources and specialised advice is required.

The current Australian CHB model of care is focused on specialist hepatological care; however, these services are facing huge demands, and it has been suggested that increased involvement of GPs is needed to deal with the growing burden of CHB,2,5,12 as well as integrated nursing models and an exploration of the role of nurse practitioners.5 The majority of surveyed GPs were most comfortable with a care model that included initial review by a specialist and continuing GP management, with less support for a model in which there was no specialist input, and a reluctance to accept review by a hepatitis clinical nurse consultant alone. The stated preference of GPs in our study for specialist input in CHB management has implications for future health service planning. If nursing support for GPs is to be successful in an alternative CHB model of care, background specialist support needs to be clearly promoted to gain the confidence of GPs and to optimise the management of CHB.

Our study has limitations. While the response rate compares favourably with other recent written GP surveys about CHB,11,13 the possibility of response bias cannot be excluded. The significant difference in sex, age distribution, and type of practice between study participants and all GPs in the surveyed LHDs affects the external validity of our findings. While the steering group provided GP input into questionnaire development to improve its face validity for GPs, we did not test the questionnaire on another group of GPs; the applicability of the instrument to other settings is therefore unclear. Closed-ended and multiple-choice questions were used to facilitate the comparability of responses; however, their use may have prevented GPs from expressing other views.

This study identified that some GPs working in areas where the prevalence of CHB is high lack confidence about managing CHB. GPs in areas where CHB is less prevalent may encounter these problems to a greater extent, but further research is necessary to confirm this assumption and to thereby inform educational programs and service planning. As the CHB burden in Australia rises and the capacity of specialist liver services is tested, a new model of care focusing on primary health care needs to be developed, but must be considered carefully, noting the clear preference of GPs for specialist support. Our results suggest that well designed and targeted support programs that include specialist support are needed as part of a model of care which ensures that GPs feel confident about managing CHB.

Box 1 –
Demographic characteristics of the study participants (n = 123) and of all general practitioners in the Sydney and South Western Sydney Local Health Districts (n = 1135)

	Study participants	All GPs	P (χ² test)

Sex			< 0.001
Female	31.7%	40.3%
Male	67.5%	59.7%
Not recorded	0.8%	0
Age group			< 0.001
< 30 years	0	0
30–39 years	10.6%	6.2%
40–49 years	26.0%	16.6%
50–59 years	32.5%	18.2%
≥ 60 years	30.1%	22.2%
Not recorded	0.8%	36.7%
Local Health District			NA
Sydney	48.0%
South Western Sydney	52.0%
Type of practice			< 0.001
Solo	35.8%	19.0%
Group	63.4%	80.8%
Not recorded	0.8%	0.3%

NA = not applicable.

Box 2 –
Confidence of general practitioners (n = 123) about different aspects of the assessment and management of patients with chronic hepatitis B (CHB)

	Very confident	Reasonably confident	Not very confident	Not at all confident	Unknown

Identifying patients at risk of CHB	49.6%	48.8%	1.6%	0	0
Screening patients at risk of CHB	52.0%	45.5%	1.6%	0	0.8%
Ordering appropriate tests for diagnosing CHB	57.7%	39.0%	2.4%	0	0.8%
Interpreting hepatitis B serology and DNA results	43.1%	47.2%	7.3%	1.6%	0.8%
Managing patients with CHB	22.8%	56.1%	17.9%	1.6%	1.6%
Undertaking surveillance of liver cancer	30.9%	57.7%	8.9%	1.6%	0.8%
Referring for fibroscan	12.2%	35.8%	35.0%	16.3%	0.8%

Box 3 –
Confidence of general practitioners (n = 123) about managing patients with chronic hepatitis B in various models of care

	Very	Reasonably	Not very	Not at all	Unknown

With no specialist input	8.9%	48.0%	29.3%	12.2%	1.6%
Initial referral to a specialist for assessment, then managed by GP	43.1%	45.5%	8.9%	0.8%	1.6%
Initial referral to a specialist for assessment, then managed by GP with support from a hepatitis clinical nurse consultant	37.4%	45.5%	9.8%	5.7%	1.6%
Initial review by a hepatitis clinical nurse consultant, then managed by GP	18.7%	40.7%	22.8%	16.3%	1.6%

Common antibiotic makes children more prone to obesity, asthma: study

A study has found a common antibiotic could make children more predisposed to becoming overweight and developing asthma.

The macrolides class of antibiotics, useful for treating lung and chest infections are used as an alternative for people who are allergic to penicillin.

A Finnish study, published in Nature Communications, examined changes in microbiota and incidence of disease in 142 children over a six-month period and supported theories that certain antibiotics early in life can have negative effects on health.

Willem de Vos and colleagues analysed the faecal microbiotia of children aged two to seven years old. They found that the use of macrolide antibiotics, but not penicillins, is associated with marked changes in gut microbiota composition that persist for over six months.

Previous studies on adults and mice have seen similar changes in microbiota that have been associated with increased risk of developing obesity and immune-related diseases.

“Among the children who received macrolides in early life, we find a positive correlation between overall lifetime antibiotic use and body mass index (BMI), as well as an increased risk of asthma, suggesting that macrolide use may alter the microbiota in infants in a way that predisposes to antibiotic-associated weight gain and asthma in later childhood,” the authors wrote.

Although more research is needed, the authors conclude: “our results support the idea that, without compromising clinical practice, the impact on the intestinal microbiota should be considered when prescribing antibiotics.”

Latest news:

[World Report] Cuba’s focus on preventive medicine pays off

Cuba’s emphasis on public health, primary care, and training thousands of medical professionals has resulted in health successes and lessons for other countries. Sam Loewenberg reports.