Reflections & Resources from the RACGP QLD Clinical Update

I escaped the rock recently and spent the long weekend in Brisbane.  In addition to the usual mainland activities (eating out, shopping, attending the local cinema and more shopping), I attended the RACGP Qld Clinical Update. I often come home from conferences feeling reinvigorated and inspired, but I never end up collating or organising my notes and ideas into anything intelligible (let alone useful).  This year, IslandDocs has motivated me to share some take home messages from the conference, as well as a few clinical pearls that will likely change my practice (and hopefully will be useful for you as well).

My favourite take home messages

Geoff Toogood is a brave and inspirational man (and cardiologist), who I could have listened to all day.  He shared his personal journey dealing with depression and anxiety and he highlighted a few things that resonated with me:

  1. We need to get better at looking after ourselves and our colleagues
  2. We also need to normalise the conversation about doctors’ mental health
  3. Essentially our culture needs to change and it’s up to us to change it – our own lives depend on it

Continue reading “Reflections & Resources from the RACGP QLD Clinical Update”

Preventative Medicine: Healthy Kai Kai & Deadly Exercise

As primary healthcare doctors we have the privilege of educating and promoting good health amongst our patients. We know that preventive medicine is essential in reducing the morbidity and mortality of chronic disease including the most commonly seen here in Torres Strait Islanders: cardiovascular disease, diabetes and chronic kidney disease.

How do you promote healthy eating and physical activity with your patients? We would love to hear from you! Sent us a tweet @Island_Docs

Continue reading “Preventative Medicine: Healthy Kai Kai & Deadly Exercise”

The Pressure Is On: Will Australia Adopt New Hypertension Guidelines?

The Evidence:

A randomised trial of intensive versus standard blood-pressure control

The Summary:

The SPRINT trial was a randomised, controlled trial comparing the safety and efficacy of intensive lowering of systolic blood pressure (SBP) to less than 120mmHg, compared with standard management to less than 140mmHg. The study included a total of 9361 patients,  who were eligible to participate if their age was greater than, or equal to, fifty years and had hypertension with a SBP greater than 130mmHg. Exclusion criteria included those patients with diabetes mellitus, previous stroke and/ or end stage renal disease. Continue reading “The Pressure Is On: Will Australia Adopt New Hypertension Guidelines?”

Iron Deficiency Anaemia

As we improve our preventative health screening practices in Remote Indigenous Health we inevitably encounter incidental abnormalities in routine pathology. Given our limited resources and developing recall systems, what do we do about them?

The ABS report that remote indigenous populations are 2-3 times as likely to suffer from anaemia compared to their urban counterparts. A prevalence of greater than 5% is considered by the World Health Organization to be of public health significance. Childhood iron deficiency anaemia has been reported as high as 90% in some remote communities and has been associated with cognitive and psychomotor delay.

Incidental Eosinophilia

As we improve our preventative health screening practices in Remote Indigenous Health we inevitably encounter incidental abnormalities in routine pathology.  Given our limited resources and developing recall systems, what do we do about them?  Over the next few weeks we will address a handful of common queries and a sensible approach to management.

Eosinophilia is a common finding in this region. Continue reading “Incidental Eosinophilia”

Urinary incontinence

Island Docs are generalists.  We strive to maintain a breadth of knowledge rather than focus on a particular specialty field.  In our efforts to provide high quality patient care, we work hard to keep up to date with the latest evidence and guidelines.  We are lucky to receive regular visiting specialists, who continue to teach us and support us.  In this section, we go back to basics and present approaches to common conditions seen in rural general practice.  We’ll also try to include any hot tips and tricks from our visiting specialists.

GP Summary: Urinary Incontinence
FROGS Outreach Teaching 13/03/2018

Continue reading “Urinary incontinence”

CKD goals, what am I doing with this raised PTH?

Phosphate-Binding Agents in Adults With CKD: A Network Meta-analysis of Randomised Trials.  Suetonia C. Palmer, PhD, Sharon Gardner, MA, Marcello Tonelli, MD, Dimitris Mavridis, PhD, David W. Johnson, PhD, Jonathan C. Craig, PhD, Richard French, MBChB, Marinella Ruospo, MScMed, Giovanni F.M. Strippoli, PhD’Correspondence information about the author PhD Giovanni F.M. Strippoli Am J Kidney Dis 2016;68:691-702. 10.1053/j.ajkd.2016.05.015

Current Australian guidelines recommend 6-12 months assessment of PTH for patients with eGFR<45.  What is the evidence for phosphate binders and which if any improve patient outcomes.

The combined effects of higher phosphate, lower calcium and lower vitamin D levels all serve to stimulate parathyroid hormone production, and in turn elevated levels of PTH increase the resorption and release of mineral from bone. It is reported that these changes have been associated with an increased risk of fracture and also increased cardiovascular mortality, perhaps mediated by accelerated vascular calcification.

  • Network meta-analysis compare and rank phosphate-binder strategies for  adults with CKD.
  • Randomized trials with allocation to phosphate binders including
    Sevelamer, lanthanum, iron, calcium, colestilan, bixalomer, nicotinic acid, and magnesium.
  • The primary outcome was all-cause mortality. Additional outcomes were cardiovascular mortality, myocardial infarction, stroke, adverse events, serum phosphorus and calcium levels, and coronary artery calcification.

77 trials (12,562 participants) were included. Most (62 trials in 11,009 patients) studies were performed in a dialysis population. Trials were generally of short duration (median, 6 months) and had high risks of bias. All-cause mortality was ascertained in 20 studies during 86,744 patient-months of follow-up. There was no evidence that any drug class lowered mortality or cardiovascular events when compared to placebo. Compared to calcium, sevelamer reduced all-cause mortality (OR, 0.39; 95% CI, 0.21-0.74), whereas treatment effects of lanthanum, iron, and colestilan were not significant (ORs of 0.78 [95% CI, 0.16-3.72], 0.37 [95% CI, 0.09-1.60], and 0.55 [95% CI, 0.07-4.43], respectively). Lanthanum caused nausea, whereas sevelamer posed the highest risk for constipation and iron caused diarrhea. All phosphate binders lowered serum phosphorus levels to a greater extent than placebo, with iron ranked as the best treatment. Sevelamer and lanthanum posed substantially lower risks for hypercalcemia than calcium.

There is currently no evidence that phosphate-binder treatment reduces mortality compared to placebo in adults with CKD.

 

Lung ultrasound for paediatric pneumonia

Q. Can Lung ultrasound reduce need for CXR in children with suspected pneumonia?

Jones BP, Tay ET, Elikashvili I, et al. Feasibility and safety of substituting lung ultrasonography for chest radiography when diagnosing pneumonia in children: a randomized controlled trial. Chest 2016;150(1):131-138.

  • randomized 191 children and adolescents with clinically suspected pneumonia to receive either CXR always followed by lung ultrasound (LUS)
  • The median patient age was 3 years, and cough, difficulty breathing and fever were the most common symptoms.
  • lung ultrasound was highly accurate for diagnosing pneumonia in children (96% sensitive, 93% specific, positive likelihood ratio = 15, negative likelihood ratio = .06).
  • Patients in the initial LUS group had fewer CXRs, with 40 of 103 patients not receiving one (NNT = 2.5 to prevent one CXR)
  • There was also no difference in unscheduled healthcare visits or antibiotic use, and there was a nonsignificant 27-minute reduction in emergency department stay in the initial LUS group. Results looked even better with more experienced sonologists.

A. Handheld ultrasound is making its way into clinical practice, and this study shows that it can safely reduce the use of chest radiography (CXR) in children with clinically suspected pneumonia and may make care more efficient.