GP on the Great Ocean Road

Intermittent broadcasting mostly around General Practice from Dr David Corbet. Surfcoast, Victoria, Australia.

[gpotgor]

the gut and more

There is a huge growth in research into the gut biome and it's implications in health and treatment options. I'm sure by now you've heard of the use of faecal transplant for treatment of C. Difficile infection. And more recently gastroenterologists have been using faecal transplants to successfully treat Irritable Bowel Syndrome. Some people are even doing it themselves at home.

A while ago I posted about Brimonidine being available for treatment of Rosacea in Australia. Since then, a patient has brought some research to my attention about the use of Rifaximin as a treatment option for Rosacea.

While the research is limited and has a lot of possible confounders (confirming Small Intestinal Bacterial Overgrowth with a non-sensitive breath test is one) there is some sense in the theory behind dysregulation of immunity and managing gut biota to address this. While not without risk, Rifaximin is only active in the gut and may be an option for those people whose Rosacea is not responsive to standard treatments.

I’m looking forward to more research coming out of gut biota projects.

[gpotgor]

Ultrasound is the way forward

I’ve always been keen on using ultrasound in primary care, but am yet to make it happen. From my time working in ED I was taught a few useful techniques such as FAST, guided peripheral IVCs, central lines and a little bit of joint diagnostics.

Earlier this week I watched an introduction to Lung ultrasound via Periscope given by JKB and filmed by Adrian Wong that unfortunately looks like is not available to watch again. In it there was basic discussion around the role of Lung Ultrasound, including understanding features of a normal image (localising through the ribs as batwings) with a sliding pleural surface, artefacts of A lines being a pleural reflection and B lines as vertical comet tails (up to 2 is ok). 

They then stepped through various diagnostic pathways and concluded with a live demonstration. Pneumothorax, pleural effusion, consolidation and the BLUE (Bedside Lung Ultrasound in Emergency) protocol were all covered. Given that lung ultrasound has excellent sensitivity for most applications - and probably outperforms CXR in certain settings I can see it would be a useful technique in primary care at point of care. Particularly where access to imaging is delayed or not available.

Time to start learning. Anyone got a spare machine?

http://www.ultrasoundpodcast.com/ http://www.sonomojo.org/foamed-ultrasound-curriculum-2/

[gpotgor]

What I learnt this week

Despite having followed Damian Roland, a paediatric emergency specialist, on twitter for some time, I had never visited his blog until recently when I stumbled onto his #WILTW with a post on Social Media Hygiene. The highlight of this post is about applying the CAGE questionnaire to social media use. Eye opener anyone?

The full list of his #WILTW posts (satisfyingly in reverse chronological order) is littered with gems about medicine, paediatrics, though process, systems, technology, communication and more. Well worth a browse if you've got time.

So I'm going to attempt my own #WILTW that I imagine will be a little more prosaic than Damian's but hopefully will be useful for reflection. It may also not happen weekly. In fact I'm sure it won't!

Switch out Drinking for Social Media and give it a go!

[gpotgor]

Rosacea option - Brimonidine gel

Rosacea is one of those diseases that seems to either be really easy to control or absolutely frustrating to treat adequately. In UpToDate it specifically mentions that trial and error is the most common approach to treatment options. As with all skin things, there's a good summary up on Dermnet (although I was surprised by the Rosex advert at the top of the screen!) that confirms we don't really know the aeitology. This goes some way to explaining why it's hard to treat in some cases. The basics apply to all patients with avoidance of precipitating factors coming front and centre (hot showers, spicy food, caffeine, alcohol all common triggers - monastic living could be useful), but I recently found out that there's a newish treatment option available for rosacea erythema which seems to be getting a good wrap on patient support group websites. Brimonidine tartrate gel was approved by the TGA in August last year lagging behind the FDA approval in 2013. The research appears to show a significant difference between the active ingredient and the carrier alone in reducing facial erythema. It's a highly selective alpha2-adrenergic receptor agonist and works through cutaneous vasoconstriction. Makes sense it can reduce erythema. Noted though are the potential adverse effects reported as: erythema, pruritus, flushing and skin burning sensation! Contraindicated in concurrent use of TCA, MAOI, tetracyclic antidepressants. Use is once daily and results are usually seen pretty quickly. Might be worth a try. References: http://dermnetnz.org/acne/rosacea.html https://www.tga.gov.au/artg/artg-id-212325 CMI and PI http://www.dermnetnz.org/treatments/brimonidine.html http://emedicine.medscape.com/article/1071429-overview

[gpotgor]

Change Day Australia - Pledge now

I was fortunate to meet Mary Freer last year at the SoMe by the Sea conference organised by Dr Helen Schultz. Mary is the CEO and director for Change Day Australia which: is a social movement that invites the health and community care workforce across Australia to make a pledge to do one thing to improve the health and wellbeing of individuals; communities and the Australian health and community care system as a whole. Awesome... and so is Mary. So, since then I've been trying to make my own pledge. It's taken some thinking because I feel there are so many things that I can do, and already am doing, to improve the health of individuals and of the communities I work in. So I started thinking about some of the things that have come up again and again throughout medical school and in my training since. One of my favourite lecturers at ANU was Christine Phillips who, in an early lecture in the Social Foundations of Medicine series, described the insurmountable knowledge mountain that is medicine. No matter how much knowledge we gain there will always be more and we will always have to keep learning. This was both reassuring and terrifying at the time - still is really. From early in training there's a lot of pressure to have the correct answer, and pimping is the classic technique applied during the formative years of a young student and doctor. I often witnessed medical students and junior doctors making up or guessing an answer, simply just to have an answer to get through the pressured situation. I'm pretty sure I did it at times too. And if you guess right, you get rewarded. Following on from this I witnessed junior doctors doing a similar thing when asked questions by patients - particularly when they didn't know the answer. And this seemed encultured all the way to the top. The consultants I admired were always the ones who would say "I don't know" and then follow up with a course of action to take. There is a culture of knowing and having answers that leaves little room for anything less. A culture like this has many potential pitfalls, and communication is at the base of them all. The pressure to be right, to have the answer, to know, coupled with the power hierarchies in medicine can limit the ability to have open dialogue. And I think, in turn, this can lead to poorer health - of doctors and patients. At some point as doctor you will make a mistake. If you haven't seen it, take a moment to watch Brian Goldman talk about doctors being wrong and the culture of denial. I rarely hear about mistakes directly from other doctors. The only time I have is when I talk about mistakes I've made first and then ask them directly if they've made mistakes. It's always uncomfortable. And I think the enculturation that occurs, around knowledge, around communication, around being right is a big part of this denial. So, I've made my pledge. To #opendialogue.

While this may sound trite, or obvious, I think it has a lot of potential to help doctors and help patients.

[gpotgor]

PBS + TGA changes to Mifepristone prescribing

From Feb 1 2015 there will be some significant changes in Australia that will enable more women to access medical termination of pregnancy. The primary change is that MS2Step registered prescribers, who are primarily GPs (Obstetricians/Gynaecologists and Dip Obs are certified to prescribe outside the MS2Step program), are now able to prescribe for gestations up to 63 days - up from 49 days. There have been changes to the packaging and more information about contraindications and precautions. In terms of precautions, the main change is that for women > 35 year of age and smoking >15 cigarettes a day, caution is advised as these women were generally excluded from clinical trials. And a new contraindication is the patient having no access to emergency medical care up to 14 days after commencing management. More info at https://www.ms2step.com.au/ for healthcare professionals. For others not able to register you can see the TGA approval information on their website.

[gpotgor]

Updates to the Therapeutic Guidelines

For those of us in Australia, the Therapeutic Guidelines (TG) is one of the "go to" sources for prescribing information. It's not the only one, but in my opinion it is the best and encompasses the use of evidence based treatment, is compiled by expert groups, and gives background and practical information including dosing and prescribing information. It costs, but if you work in a public hospital or AMS (see my previous post) you can access it via the Victorian Clinician's Health Channel for free. I also used it a lot when I was a medical student, so it's become quite embedded in my practice. I've even been known to read it for pleasure. This post is about some of the recent changes to the Antibiotic section of the TG, which have been significant in a number of areas. The introduction has a few changes and aims to support appropriate and optimised prescribing. They utilise the mnemonic MIND ME, thus:

While obvious and straight forward, this "creed" is always useful to consider. It also underpins the rest of the introductory section. For all of us, it's worth reading the antimicrobial resistance and stewardship sections - and follow the links through to NPS and ACSQHC websites for more info and practice guidelines. For GPs, the update includes some practical guidance for the management of acute gastroenteritis - in particular in aged care but also with a new treatment algorithm for early management and a comparison of microbiological testing for Clostridium Difficile. There have been a lot of changes in the pneumonia section with comprehensive notes about the rationale behind empiric antibiotic regimens in mild community acquired pneumonia - including the use of combination therapy when required (basically if no improvement on clinical review 48 hours after commencing monotherapy - or if you can't review them within 48 hours). In case you were wondering, the combination in question in amoxycillin 1g TDS for 5-7/7 and doxycycline 100mg BD for 5-7/7. Just an aside... how many doctors do you know prescribe roxithromycin for chest infections? Seems like a relatively common occurrence and not just used for hypersensitivity to penicillin. For a more detailed coverage on the changes, check out the TG press release [pdf]. Happy reading and appropriate prescribing! * As a footnote, I'd like to commend the TG for the correct use of the word regimen when describing a course of prescription, rather than the often misused term regime, which is something altogether different. Please feel free to correct your colleagues at will.

[gpotgor]

Access to the Victorian Clinicans Health Channel

The Victorian Clinicians Health Channel is a portal website that provides access to lots of electronic resources for health practitioners who work in the public health sector (in Victoria, Australia in case that wasn't clear). As a junior doctor this was a great resource for accessing clinical information, and in particular access to some mobile resources such as iMIMS (or mobile MIMS for the non-iPhonecentric), BMJ Best Practice, eTG, and the AMH (and more). The good news is that if you work in an Aboriginal Community Controlled Health Organisation in Victoria you can also access these resources for free. Head over to http://www.health.vic.gov.au/clinicians/registration.htm to register. If you're at an ACCHO / AMS then in the Your Hospital or Health Service Details section select 'Other' and 'Aboriginal Community Health Services'. Then follow the various instructions to register for the mobile service you're interested in. Bingo!

[gpotgor]

Changes to the MBS

From November 1 2014 there have been a number of changes to rebates for pathology tests that will have a significant impact on General Practitioners. The main one being the use of the HbA1c for diagnosis of Diabetes Mellitus. For those of you short on time, here's the low down: you can now order a single HbA1c test every 12 months for asymptomatic high risk patients to diagnose diabetes. A result equal to or above 48 mmol/mol (or 6.5% in the old usage) is diagnostic, although lower readings don't necessarily exclude diabetes. Hooray! You can download the official documentation from Medicare here. For those of you with nothing better to do, read on for a little more info and feel free to add comments, ask questions or get involved. Many countries already use HbA1c, a measure of long term blood glucose control, for diagnosis of diabetes with threshold criteria adequately described in the literature. In Australia we use a fasting glucose of ≥ 7mmol/L (measured on two separate occasions) for diagnosis, or more commonly, having found a raised but non-diagnostic fasting glucose, a postprandial glucose ≥ 11.0 mmol/L from a Glucose Tolerance Test (GTT) (also meant to be on two separate occasions). The GTT is a time and resource consuming test, where a glucose load is given to a fasting patient and their blood glucose levels measured 3 times over a two hour period. Lots of patients have complained to me about the glucose load, primarily due to the intense sweetness and the occasional nauseous vomit. Up until November 1 this year you could order an HbA1c to monitor control of blood glucose in a patient with known diabetes and receive the medicare rebate 4 times a year. This hasn't changed, but now there is a rebate available to diagnose “high risk” asymptomatic patients: Quantitation of HbA1c (glycated haemoglobin) performed for the diagnosis of diabetes in asymptomatic patients at high risk. (Item is subject to rule 25) Rule 25 appears to relate to the frequency of testing – in this case only once every 12 months to get a rebate. A quick search on the medicare website failed to provide a list of the rules, but I'm curious to read them if anyone has access. So, what criteria determines if a patient is high risk? I think it's safe to say that we can rely on the AUSDRISK guidelines / evaluation to determine high risk patients, defined as a score of 12 or more. Then again, given the machinations of medicare, it's probably best not to assume anything! The RACGP 2014-2015 guidelines do support the use of HbA1c ≥ 48 mmol/mol for diagnosis but state readings needed on two separate occasions. It will be interesting to see how they adjust their flow chart for diagnosis to accommodate that only one HbA1c test would get the rebate under the current system! Other considerations Limitations of the HbA1C: Given the assay evaluates glycated haemoglobin from red blood cells, anything that reduces the survival time of red cells will change the result. This becomes important when considering co-morbidities, such as chronic renal failure, post-splenectomy, anaemia and haemoglobinopathies – although the effect of haemoglobinopathies also depends on the type and it's recommended you talk to your local friendly path lab first if ordering the test. In patients who have had a blood transfusion or therapeutic venesection it is necessary to wait for 3 months to do the test. Money: The GTT costing from the MBS website shows Fee: $18.95 Benefit: 75% = $14.25 85% = $16.15 and for the HbA1c Fee: $16.80 Benefit: 75% = $12.60 85% = $14.30 What's not to like! Lower cost, equivalent diagnostic test, less resource dependent, more tolerable test, meets international standards. Well done medicare. The next post will cover some of the other changes. Including strict criteria for Vitamin D testing. Resources: http://www.australianprescriber.com/magazine/37/3/98/100 http://download.journals.elsevierhealth.com/pdfs/journals/0168-8227/PIIS0168822711001318.pdf http://www.nps.org.au/medical-tests/pathology-tests/for-individuals/blood-tests/for-individuals/hba1c-test http://www.health.gov.au/internet/mbsonline/publishing.nsf/Content/Downloads-2014-11 http://rcpamanual.edu.au/ http://www.health.gov.au/preventionoftype2diabetes

[gpotgor]

lift off

in an effort to restart blogging, and to contribute to #FOAM4GP I've started this new tumblr. didn't have time to think about setting up a new site. and my mostly inactive old tumblr account didn't feel like the right place. so, for now. here we are