Royal Australian College of General Practitioners



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KEY GP – FEBRUARY 2021

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American Family Physician Vol. 103 No. 1 January 1 2021

Khan M, Chollet A.

Breast Cancer Screening: Common Questions and Answers.

pp33-41. PMID: 33382554.

Breast cancer is the most common nonskin cancer in women and accounts for 30% of all new cancers in the United States. The highest incidence of breast cancer is in women 70 to 74 years of age. Numerous risk factors are associated with the development of breast cancer. A risk assessment tool can be used to determine individual risk and help guide screening decisions. The U.S. Preventive Services Task Force (USPSTF) and American Academy of Family Physicians (AAFP) recommend against teaching average-risk women to perform breast self-examinations. The USPSTF and AAFP recommend biennial screening mammography for average-risk women 50 to 74 years of age. However, there is no strong evidence supporting a net benefit of mammography screening in average-risk women 40 to 49 years of age; therefore, the USPSTF and AAFP recommend individualized decision-making in these women. For average-risk women 75 years and older, the USPSTF and AAFP conclude that there is insufficient evidence to recommend screening, but the American College of Obstetricians and Gynecologists and the American Cancer Society state that screening may continue depending on the woman's health status and life expectancy. Women at high risk of breast cancer may benefit from mammography starting at 30 years of age or earlier, with supplemental screening such as magnetic resonance imaging. Supplemental ultrasonography in women with dense breasts increases cancer detection but also false-positive results.

Ford B, Dore M, Moullet P.

Diagnostic Imaging: Appropriate and Safe Use.

pp42-50. PMID: 33382559.

The use of diagnostic radiography has doubled in the past two decades. Image Gently (children) and Image Wisely (adults) are multidisciplinary initiatives that seek to reduce radiation exposure by eliminating unnecessary procedures and offering best practices. Patients with an estimated glomerular filtration rate less than 30 mL per minute per 1.73 m2 may have increased risk of nephropathy when exposed to iodinated contrast media and increased risk of nephrogenic systemic fibrosis when exposed to gadolinium-based contrast agents. American College of Radiology Appropriateness Criteria can help guide specific diagnostic imaging choices. Noncontrast head computed tomography is the first-line modality when a stroke is suspected. Magnetic resonance imaging stroke protocols and computed tomography perfusion scans can augment evaluation and potentially expand pharmacologic and endovascular therapy timeframes. Imaging should be avoided in patients with uncomplicated headache syndromes unless the history or physical examination reveals red flag features. Cardiac computed tomography angiography, stress echocardiography, and myocardial perfusion scintigraphy (nuclear stress test) are appropriate for patients with chest pain and low to intermediate cardiovascular risk and have comparable sensitivity and specificity. Computed tomography pulmonary angiography is the preferred test for high-risk patients or those with a positive d-dimer test result, and ventilation-perfusion scintigraphy is reserved for patients with an estimated glomerular filtration rate less than 30 mL per minute per 1.73 m2 or a known contrast allergy. Computed tomography with intravenous contrast is preferred for evaluating adults with suspected appendicitis; however, ultrasonography should precede computed tomography in children, and definitive treatment should be initiated if positive. Ultrasonography is the first-line modality for assessing right upper quadrant pain suggestive of biliary disease. Mass size and patient age dictate surveillance recommendations for adnexal masses. Imaging should not be performed for acute (less than six weeks) low back pain unless red flag features are found on patient history. Ultrasonography should be used for the evaluation of suspicious thyroid nodules identified incidentally on computed tomography.

Klein DA, Sylvester JE, Schvey NA.

Eating Disorders in Primary Care: Diagnosis and Management.

pp22-32. PMID: 33382560.

Eating disorders are potentially life-threatening conditions characterized by disordered eating and weight-control behaviors that impair physical health and psychosocial functioning. Early intervention may decrease the risk of long-term pathology and disability. Clinicians should interpret disordered eating and body image concerns and carefully monitor patients' height, weight, and body mass index trends for subtle changes. After diagnosis, visits should include the sensitive review of psychosocial and clinical factors, physical examination, orthostatic vital signs, and testing (e.g., a metabolic panel with magnesium and phosphate levels, electrocardiography) when indicated. Additional care team members (i.e., dietitian, therapist, and caregivers) should provide a unified, evidence-based therapeutic approach. The escalation of care should be based on health status (e.g., acute food refusal, uncontrollable binge eating or purging, co-occurring conditions, suicidality, test abnormalities), weight patterns, outpatient options, and social support. A healthy weight range is determined by the degree of malnutrition and pre-illness trajectories. Weight gain of 2.2 to 4.4 lb per week stabilizes cardiovascular health. Treatment options may include cognitive behavior interventions that address body image and dietary and physical activity behaviors; family-based therapy, which is a first-line treatment for youths; and pharmacotherapy, which may treat co-occurring conditions, but should not be pursued alone. Evidence supports select antidepressants or topiramate for bulimia nervosa and lisdexamfetamine for binge-eating disorder. Remission is suggested by healthy biopsychosocial functioning, cognitive flexibility with eating, resolution of disordered behaviors and decision-making, and if applicable, restoration of weight and menses. Prevention should emphasize a positive focus on body image instead of a focus on weight or dieting.

Joynes A.

Chronic Dyspnea.

p8. PMID:33382568.

Mammogram Screening for Breast Cancer.

Online. PMID: 33382571.

Neamand-Cheney KA, Carroll EB.

Persistent Submandibular Abscess.

pp51-52. PMID: 33382564.

Nissley JA.

Treatment of Distal DVT.

pp18-19. PMID: 33382566.

Arnold MJ, Fulleborn S, Farrell J.

Medications for Treatment-Resistant Depression in Adults.

pp16-18. PMID: 33382567.

Huhndorf J, Curtis T, Neher J, et al.

Electronic Cigarettes for Smoking Cessation.

pp53-54. PMID: 33382561.

Fink D, Mayes JL.

Making Recommendations to Reduce Noise Exposure.

pp57-59. PMID: 33382563.

Bryce C, Bucaj M. CT

Colonography for Colorectal Cancer Screening.

pp55-56. PMID: 33382558.

Mammography, Lymphomas, Hypertension in Pregnancy, Dyspepsia.

p15. PMID: 33382555.

Ver C, Garcia C, Bickett A.

Intimate Partner Violence During the COVID-19 Pandemic.

pp6-7. PMID: 33382569.

Sexton SM, Richardson CR, Schrager SB, et al.

Systemic Racism and Health Disparities: A Statement from Editors of Family Medicine Journals.

pp10-11. PMID: 33382565.

Stovitz SD, Thompson JA, Demmer RT.

Beware of the Differing Definitions for the False-Positive Rate.

pp7-8. PMID: 33382570.

Wilkinson E, Jabbarpour Y.

Increasing Share of Practicing Female Family Physicians, 2010-2020.

p12. PMID: 33382562.

Buelt A.

Testosterone Therapy for Age-Related Low Testosterone: Guidelines from the ACP.

pp60-61. PMID: 33382552.

Baird D, Atchison R.

Effectiveness of Alarm Therapy in the Treatment of Nocturnal Enuresis in Children.

Online. PMID: 33382553.

American Family Physician Vol. 103 No. 2 January 15 2021

Wilkinson JM, Codipilly DC, Wilfahrt RP.

Dysphagia: Evaluation and Collaborative Management.

pp97-106. PMID: 33448766.

Dysphagia is common but may be underreported. Specific symptoms, rather than their perceived location, should guide the initial evaluation and imaging. Obstructive symptoms that seem to originate in the throat or neck may actually be caused by distal esophageal lesions. Oropharyngeal dysphagia manifests as difficulty initiating swallowing, coughing, choking, or aspiration, and it is most commonly caused by chronic neurologic conditions such as stroke, Parkinson disease, or dementia. Symptoms should be thoroughly evaluated because of the risk of aspiration. Patients with esophageal dysphagia may report a sensation of food getting stuck after swallowing. This condition is most commonly caused by gastroesophageal reflux disease and functional esophageal disorders. Eosinophilic esophagitis is triggered by food allergens and is increasingly prevalent; esophageal biopsies should be performed to make the diagnosis. Esophageal motility disorders such as achalasia are relatively rare and may be overdiagnosed. Opioid-induced esophageal dysfunction is becoming more common. Esophagogastroduodenoscopy is recommended for the initial evaluation of esophageal dysphagia, with barium esophagography as an adjunct. Esophageal cancer and other serious conditions have a low prevalence, and testing in low-risk patients may be deferred while a four-week trial of acid-suppressing therapy is undertaken. Many frail older adults with progressive neurologic disease have significant but unrecognized dysphagia, which significantly increases their risk of aspiration pneumonia and malnourishment. In these patients, the diagnosis of dysphagia should prompt a discussion about goals of care before potentially harmful interventions are considered. Speech-language pathologists and other specialists, in collaboration with family physicians, can provide structured assessments and make appropriate recommendations for safe swallowing, palliative care, or rehabilitation.

LeFevre NM, Krumm E, Cobb WJ.

Labor Dystocia in Nulliparous Women.

pp90-96. PMID: 33448772.

Dystocia (abnormally slow or protracted labor) accounts for 25% to 55% of primary cesarean deliveries. The latent phase of labor begins with onset of regular, painful contractions and continues until 6 cm of cervical dilation. Current recommendations are to avoid admission to labor and delivery during the latent phase, assuming maternal/fetal status is reassuring. The active phase begins at 6 cm. An arrested active phase is defined as more than four hours without cervical change despite rupture of membranes and adequate contractions and more than six hours of no cervical change without adequate contractions. Managing a protracted active phase includes oxytocin augmentation with or without amniotomy. The second stage of labor begins at complete cervical dilation and continues to delivery. This stage is considered protracted if it lasts three hours or more in nulliparous patients without an epidural or four hours or more in nulliparous patients with an epidural. Primary interventions for a protracted second stage include use of oxytocin and manual rotation if the fetus is in the occiput posterior position. When contractions or pushing is inadequate, vacuum or forceps delivery may be needed. Effective measures for preventing dystocia and subsequent cesarean delivery include avoiding admission during latent labor, providing cervical ripening agents for induction in patients with an unfavorable cervix, encouraging the use of continuous labor support (e.g., a doula), walking or upright positioning in the first stage, and not diagnosing failed induction during the latent phase until oxytocin has been given for 12 to 18 hours after membrane rupture. Elective induction at 39 weeks' gestation in low-risk nulliparous patients may reduce the risk of cesarean delivery.

Hip Pain in Adults.

Online. PMID: 33448778.

Chamberlain R.

Hip Pain in Adults: Evaluation and Differential Diagnosis.

pp81-89. PMID: 33448767.

Adults commonly present to their family physicians with hip pain, and diagnosing the cause is important for prescribing effective therapy. Hip pain is usually located anteriorly, laterally, or posteriorly. Anterior hip pain includes referred pain from intra-abdominal or intrapelvic causes; extra-articular etiologies, such as hip flexor injuries; and intra-articular etiologies. Intra-articular pain is often caused by a labral tear or femoroacetabular impingement in younger adults or osteoarthritis in older adults. Lateral hip pain is most commonly caused by greater trochanteric pain syndrome, which includes gluteus medius tendinopathy or tear, bursitis, and iliotibial band friction. Posterior hip pain includes referred pain such as lumbar spinal pathology, deep gluteal syndrome with sciatic nerve entrapment, ischiofemoral impingement, and hamstring tendinopathy. In addition to the history and physical examination, radiography, ultrasonography, or magnetic resonance imaging may be needed for a definitive diagnosis. Radiography of the hip and pelvis should be the initial imaging test. Ultrasound-guided anesthetic injections can aid in the diagnosis of an intra-articular cause of pain. Because femoroacetabular impingement, labral tears, and gluteus medius tendon tears typically have good surgical outcomes, advanced imaging and/or early referral may improve patient outcomes.

Earp BD, Mishori R, Rotta AT.

Newborn Circumcision Techniques and Medical Ethics.

pp69-70. PMID: 33448775.

Pippin M, Buller L.

Fever and Rash After Travel to the Philippines.

pp113-114. PMID: 33448765.

Wenstrup S, Goel D, Viqar B.

Antepartum Perineal Massage for Intrapartum Lacerations.

pp115-116. PMID: 33448760.

Buelt A, Narducci DM.

Osteoarthritis Management: Updated Guidelines from the American College of Rheumatology and Arthritis Foundation.

pp120-121. PMID: 33448759.

Screening for Unhealthy Drug Use: Recommendation Statement.

pp107-112. PMID: 33448774.

Shaughnessy AF.

Short-Term Low Back Pain Relief with Placebo.

Online. PMID: 33448773.

Coles S, Vosooney A.

Evidence Lacking to Support Universal Unhealthy Drug Use Screening.

pp72-73. PMID: 33448770.

Ehrlich AM, Trow TK.

Blood Transfusion Decisions in Adults with Nonvariceal Upper Gastrointestinal Bleeding.

pp68-69. PMID: 33448777.

COVID-19, Scoliosis, Muscle Weakness, Preterm Birth, Fecal Incontinence.

p78. PMID: 33448764.

Myran L, Nguyen TN.

Icosapent Ethyl (Vascepa) for Hyperlipidemia/Hypercholesterolemia to Reduce Risk of Heart Attack and Stroke.

pp117-118. PMID: 33448769.

Hay W.

Low Specificity Limits Use of Test for Spondylolysis in Children and Adolescents.

p68. PMID: 33448776.

Slawson DC, Garcia CM.

Buffering Lidocaine 1%/ Epinephrine with Sodium Bicarbonate in a 3:1 Ratio Is as Effective and Less Painful than a 9:1 Ratio.

Online. PMID: 33448771.

Ebell MH.

Triple Inhaled Therapy Provides a Small Reduction in Moderate COPD Exacerbations, No Effect on Severe Exacerbations.

Online. PMID: 33448761.

Slawson DC.

Twenty-Year Follow-Up of Women's Health Initiative Trials: Lower Breast Cancer Mortality with Estrogen Alone, No Difference with Estrogen Plus Progesterone.

Online. PMID: 33448768.

British Journal of General Practice Vol. 71 No. 702 December 28 2020

Miller S.

And then there was one.

p36. doi:10.3399/bjgp21X714569. PMID: 33372096; PMCID: PMC7759361.

Lawson E.

Legislating for the Future: Reshaping Laws.

p3. doi:10.3399/bjgp21X714329. PMID: 33372083; PMCID: PMC7759364.

Laake JP, Majeed N, Walters K.

Realising the potential of Improving Access to Psychological Therapies for older adults.

pp8-9. doi:10.3399/bjgp21X714365. PMID: 33372086; PMCID: PMC7759355.

Evans PH, Choules J.

Lady Pereira Gray: an appreciation.

p30. doi:10.3399/bjgp21X714509. PMID: 33372091; PMCID: PMC7759374.

Dobler E.

General practice during COVID-19: an FY2's perspective.

p25. doi:10.3399/bjgp21X714473. PMID: 33372088; PMCID: PMC7759368.

Barrett K.

Microscopic colitis: a guide for general practice.

pp41-42. doi:10.3399/bjgp21X714593. PMID: 33372097; PMCID: PMC7759366.

Hull S, Ashman N, Dreyer G.

Inequalities in CKD management can be overcome.

p12. doi:10.3399/bjgp21X714389. PMID: 33372099; PMCID: PMC7759356.

Gopal DP, Calderón-Larrañaga S.

Gut feeling is changing in the post-coronavirus world.

p24. doi:10.3399/bjgp21X714461. PMID: 33372087; PMCID: PMC7759378.

Zigmond D.

How and why have we so hazardously misconceived our NHS staff?

pp26-27. doi:10.3399/bjgp21X714485. PMID: 33372089; PMCID: PMC7759367.

Clark CE, Masoli J, Warren FC, et al.

Vitamin D and COVID-19 in older age: evidence versus expectations.

pp10-11. doi:10.3399/bjgp21X714377. PMID: 33355153; PMCID: PMC7759342.

Howell S, Torabi P.

It's time to look again at GP funding.

pp12-13. doi:10.3399/bjgp21X714401. PMID: 33372100; PMCID: PMC7759354.

Rashid A.

Yonder: Locum doctors, testicular pain, chaplaincy services, and mumsnet.

p31. doi:10.3399/bjgp21X714521. PMID: 33372092; PMCID: PMC7759359.

Agarwal G, Pirrie M, Marzanek F, et al.

Time to reshape our delivery of primary care to vulnerable older adults in social housing?

pp6-7. doi:10.3399/bjgp21X714353. PMID: 33372085; PMCID: PMC7759362.

Osborne E, Bilalian C, Cussans A, et al.

Pseudomonas folliculitis: a complication of the lockdown hot tub boom? Lessons from a patient.

pp43-44. doi:10.3399/bjgp21X714605. PMID: 33372098; PMCID: PMC7759351.

Avini E, Omran Q, Mohamed F, et al.

Ambivalent sexism within medicine: reflections from four medical students.

pp28-29. doi:10.3399/bjgp21X714497. PMID: 33372090; PMCID: PMC7759376.

Khunti K, Routen A, Patel K, et al.

Focused action is required to protect ethnic minority populations from COVID-19 post-lockdown.

pp37-40. doi:10.3399/bjgp21X714581. PMID: 33355159; PMCID: PMC7759346.

Mroz G, Papoutsi C, Rushforth A, et al.

Changing media depictions of remote consulting in COVID-19: analysis of UK newspapers.

e1-e9. doi:10.3399/BJGP.2020.0967. PMID: 33318086; PMCID: PMC7759365.

Soley-Bori M, Ashworth M, Bisquera A, et al.

Impact of multimorbidity on healthcare costs and utilisation: a systematic review of the UK literature.

e39-e46. doi:10.3399/bjgp20X713897. PMID: 33257463; PMCID: PMC7716874.

Leigh S, Mehta B, Dummer L, et al.

Management of non-urgent paediatric emergency department attendances by GPs: a retrospective observational study.

e22-e30. doi:10.3399/bjgp20X713885. PMID: 33257462; PMCID: PMC7716877.

Background: Non-urgent emergency department (ED) attendances are common among children. Primary care management may not only be more clinically appropriate, but may also improve patient experience and be more cost-effective.

Aim: To determine the impact on admissions, waiting times, antibiotic prescribing, and treatment costs of integrating a GP into a paediatric ED.

Design and setting: Retrospective cohort study explored non-urgent ED presentations in a paediatric ED in north-west England.

Method: From 1 October 2015 to 30 September 2017, a GP was situated in the ED from 2.00 pm until 10.00 pm, 7 days a week. All children triaged as 'green' using the Manchester Triage System (non-urgent) were considered to be 'GP appropriate'. In cases of GP non-availability, children considered non-urgent were managed by ED staff. Clinical and operational outcomes, as well as the healthcare costs of children managed by GPs and ED staff across the same timeframe over a 2-year period were compared.

Results: Of 115 000 children attending the ED over the study period, a complete set of data were available for 13 099 categorised as 'GP appropriate'; of these, 8404 (64.2%) were managed by GPs and 4695 (35.8%) by ED staff. Median duration of ED stay was 39 min (interquartile range [IQR] 16-108 min) in the GP group and 165 min (IQR 104-222 min) in the ED group (P4 hours before being admitted or discharged (OR 0.11; 95% CI = 0.08 to 0.13), but were more likely to receive antibiotics (OR 1.42; 95% CI = 1.27 to 1.58). Treatment costs were 18.4% lower in the group managed by the GP (P ................
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