The assessment and treatment of behavioural problems

BACKGROUND

While general practitioners acknowledge their responsibility for the medical management of people with intellectual disability and autism, there may be a need for more skill in the assessment and management of behavioral problems.

OBJECTIVE

This article provides an overview of services for this group of patients, the role of the GP, and provides a guide to assessment and treatment of behavioural problems.

DISCUSSION

While GPs have skills in medical and psychiatric assessment, the different social, cognitive and communicative context in this group of people limits their ability to apply those skills. Nonetheless, familiarity with the patient and their social environment means that GPs have an important and central role in the ongoing management of patients with an intellectual disability.

Rehabilitation for postpolio sequelae

BACKGROUND

Postpolio sequelae (PPS) are new, late manifestations that occur many years after the initial poliomyelitis infection. Recurrence of symptoms and fear of reactivation of the polio virus is particularly distressing to polio survivors.

OBJECTIVE

This article outlines the diagnosis, pathophysiology, and management of PPS disabilities using a case vignette.

DISCUSSION

Clinical features of PPS include fatigue, joint and muscle pain, new muscular weakness and bulbar symptoms. Diagnosis can be complicated particularly in nonparalytic cases of poliomyelitis. Disabilities in PPS may not be obvious to the observer but significantly affect the quality of life of the PPS patient. Previous rehabilitation intervention focussed on physical effort and determination to overcome disability at all costs. The treatment in PPS is now modified, and aggressive physical measures that may exacerbate muscle weakness are avoided. Most disabilities in PPS can be well managed with rehabilitation interventions that address limitations in patient activities of daily living, mobility and cardiopulmonary fitness.

Secondary prevention of overweight in primary school children: what place for general practice?

At least a quarter of primary school children in Australia are overweight or obese; the long-term impacts are likely to include chronic morbidity and loss of life-years. Universal preventive strategies have so far had limited effectiveness, while secondary and tertiary referral services would be overwhelmed if they attempted to systematically manage a problem with such high prevalence. Primary care services could play an important role in secondary prevention of overweight and mild obesity in children. While reports of child obesity research have burgeoned since 1995, effectiveness trials of primary care interventions in primary-school-aged children have been neglected. Randomised controlled trials of a primary care approach, although challenging, are essential to determine whether it does more good than harm.

How is the high vaginal swab used to investigate vaginal discharge in primary care and how do GPs' expectations of the test match the tests performed by their microbiology services?

OBJECTIVES

To describe the management of vaginal discharge in general practice, with particular regard to the use of the high vaginal swab (HVS), and to compare GPs' expectations of this test with the processing and reporting undertaken by different laboratories.

METHODS

A postal questionnaire survey of 2146 GPs in the North Thames area and postal questionnaire study of the 22 laboratories serving the same GPs were carried out. GPs were asked how they would manage a young woman with vaginal discharge and what information they would like on an HVS report. Laboratories were asked how they would process and report on the HVS sample from the same patient.

RESULTS

Response rate was 26%. 72% of GPs would take an HVS and 62% would refer on to a genitourinary medicine (GUM) clinic. 45% would offer empirical therapy and 47% of these would treat for candida initially. 75% of GPs routinely request "M,C&S" on HVS samples but 55% only want to be informed about specific pathogens. Routine processing of HVS samples varies widely between laboratories and 86% only report specific pathogens. 78% of GPs would like to be offered a suggested diagnosis on HVS reports, and 74% would like a suggested treatment. 43% of laboratories ever provide a diagnosis, and 14% provide a suggested treatment.

CONCLUSIONS

GPs frequently manage vaginal discharge and most of them utilise the HVS. GPs' expectations of the test are not well matched to laboratory processing or reporting of the samples.

A systematic review of brachytherapy. Is it an effective and safe treatment for localised prostate cancer?

BACKGROUND

Brachytherapy is a promising treatment for prostate cancer as it may have reduced rates of impotence and incontinence.

OBJECTIVE

General practitioners can influence the treatment patients receive by their referral patterns, so it is important they understand the effectiveness and safety of treatment. We reviewed the primary literature on brachytherapy as sole therapy for localised prostate cancer.

DISCUSSION

Although there have been many studies on the safety and effectiveness of brachytherapy, there have been no trials of brachytherapy versus other treatments that would control for factors such as tumour stage, grade, or initial prostate specific antigen levels. Brachytherapy for localised prostate cancer appears to have equivalent survival rates to surgery and lower rates of impotence and urinary incontinence.

Injecting drug use and skin lesions

BACKGROUND

Many illicit drugs can be injected, with this mode of administration associated with a range of skin morbidities.

OBJECTIVE

This article illustrates a dermatological presentation associated with injecting drug use.

DISCUSSION

Track marks, injection site marks and skin abscesses are well known to be associated with injecting drug use. However, there are other dermatological manifestations that are less commonly known. Signs may be more subtle, particularly when drug use is recreational and patients do not fit commonly held stereotypes of injecting drug users.

Itch: a symptom of occult disease

BACKGROUND

Pruritus, (the Latin word for itch), is defined as the 'desire to scratch'. It is a distressing, subjective symptom that may interfere significantly with the quality of a patient's life.

OBJECTIVE

This article summarises the systemic causes of pruritus, describes the assessment of a patient presenting with itch without dermatological cause, and discusses the management of itch in patients with cancer.

DISCUSSION

Patients with pruritus that does not respond to conservative therapy should be evaluated for underlying systemic disease. Causes of systemic pruritus include cholestasis, thyroid disease, polycythaemia rubra vera, uraemia, Hodgkin disease, and HIV. A thorough history and a complete physical examination are central to the evaluation of pruritus. In the absence of skin lesions, diagnostic testing is directed by the clinical evaluation and may include a complete blood count, liver function tests, serum creatinine, blood urea nitrogen levels, measurement of thyroid stimulating hormone, and chest X-ray. Removal of the causative agent and appropriate investigation and treatment of the underlying disease are essential first line measures in the treatment of pruritus.

Which test to detect microalbuminuria in diabetic patients? A systematic review

BACKGROUND

Current guidelines suggest general practitioners should screen their diabetic patients for microalbuminuria. There is a range of possible tests. We looked for studies that compared a timed urine sample (the gold standard) with a random spot sample.

METHOD

Systematic review and meta analysis of studies comparing albumin to creatinine ratio (ACR) on a random specimen to albumin excretion rate from an overnight or 24 hour timed sample. Studies were identified using Medline and EMBASE to June 2003. Studies were pooled using diagnostic odds ratios and were checked for heterogeneity.

RESULTS

Ten studies covering 1470 patients were included. Use of the ACR in screening 100 diabetic patients would miss only two out of the 20 patients who would be expected to have microalbuminuria, while there would be 13 false positives. A timed specimen would be required to clarify the diagnosis for 31 patients.

DISCUSSION

The marginal benefit of using a timed urine collection over a spot ACR to detect microalbuminuria in the screening of diabetic patients is small, and not worth the cost and inconvenience of collecting a timed sample.

Urticaria

BACKGROUND

Urticaria is a very common problem that affects most of the population at some time. Acute urticaria is often allergy based and self limiting. In chronic urticaria, it is uncommon to find an allergic cause and in most cases, it is more useful to consider it as an autoimmune disease.

OBJECTIVE

This article reviews the assessment of urticaria and outlines a treatment plan for chronic urticaria.

DISCUSSION

In most patients, urticaria is acute and self limiting and settles with the aid of antihistamines. Chronic urticaria is more challenging for both the doctor and patient. A careful history is important in Identifying allergic causes and aggravating factors. In severe cases, immunosuppressive therapy may be required.

Vulval itch

BACKGROUND

Vulval itch is common. Patients presenting with this symptom can have a long history involving visits to several general practitioners. Self diagnosis as thrush is common, and inappropriate use of over-the-counter antifungal preparations can lead to further irritation and distress. Excoriation, rubbing, maceration, secondary infection and the effects of topical applications frequently complicate matters.

OBJECTIVE

This article identifies the common causes of vulval itch in adults and children, and highlights key features of the diagnosis and management of these conditions. Vulval pain syndromes are beyond the scope of this article and are therefore not discussed.

DISCUSSION

The cause of vulval itch can often be multifactorial, but with careful assessment, a primary diagnosis can be reached in most cases. A good history requires patience, and gentle direct questioning, as patients often feel uncomfortable discussing their problems and may not disclose self applied remedies. Care should be taken during examination, as vulval rashes may be subtle. All postpubertal patients should have a low vaginal swab to diagnose candidiasis rather than treating empirically.

Demystifying the FRACGP exam

In the initial stages of examination preparation, many candidates for the Fellowship of The Royal Australian College of General Practitioners (FRACGP) feel overwhelmed by the perceived complexity and magnitude of the impending exam. This article describes an exam workshop for general practice registrars in Western Australia that provides case based and context based (ie. as if in your practice) learning experiences to address this anxiety. It aims to provide FRACGP candidates with a practical approach to exam preparation. One general practice patient case is worked through in stages, and the information obtained is related to the six question types as found in the FRACGP exam. This article will be useful for anyone contemplating sitting the FRACGP exam, general practitioner supervisors, and others involved in the education of general practice registrars.

Pruritus ani

BACKGROUND

Pruritus ani is a common presenting problem in general practice, one that is particularly distressing to patients. However, there is little available research on which to base management

OBJECTIVE

This article discusses the causes and management of this distressing symptom based on thecurrent available evidence.

DISCUSSION

Perianal itch probably arises from localised inflammation. This may be the result of anorectal disease, skin disorders, excessive cleaning, application of local irritants or other causes. In children, perianal itch may be caused by intestinal hermetic Infection such as pinworm. Whatever the initial cause, the problem may at times become chronic, with scratching inflaming the area and more itching resulting. Avoiding trauma from excess washing, toilet paper and topical agents is important. Treatments likely to be effective are emollients such as sorbolene, a short course of topical hydrocortisone cream and capsaicin cream.

Why am I so itchy?

BACKGROUND

Virtually all of us experience an itch at some time. However, for some people, an intense or persistent itch can cause considerable morbidity that often affects the entire family.

OBJECTIVE

This article gives an overview of the problem of itch, and discusses the assessment and management of atopic eczema, scabies, lichen planus and dermatitis herpetiformis.

DISCUSSION

A good history will nearly always provide the diagnosis. Examination can then be targeted at finding specific signs. The distribution of rash is important, as is examination of the nails and mouth. Simple but helpful investigations such as microscopy and skin biopsy can be carried out in the consulting room. If a patient presents with a very itchy rash, consider four main possibilities: eczema, scabies, lichen planus and dermatitis herpetiformis, with the first two being the most common. For chronic conditions such as eczema, structured follow up is essential.

Encouraging GP alcohol intervention: pilot study of change-orientated reflective listening (CORL)

AIMS

To test the feasibility of delivery and potential value of a brief motivational enhancement intervention targeting GPs in relation to alcohol as a public health issue, and to compare data obtained with similar attempts to influence GP intervention with drug users.

METHOD

21 GPs who were not involved in the treatment of drug dependence received a telephone-administered 'change-orientated reflective listening' (CORL) intervention, based on Motivational Interviewing, with an informational adjunct. Assessments were made at baseline and at 2-3 months of activity and willingness to deliver specified alcohol-related interventions, plus overall therapeutic commitment and motivation. Qualitative data was obtained.

RESULTS

There was no change over time in the sample as a whole, with very modest evidence of benefit among individual practitioners. Comparisons with cannabis and drug misuse intervention targets suggest that it may be more difficult to alter views on intervening with drinkers.

CONCLUSIONS

Further attempts are needed to influence practitioner motivation, based on improved understanding of GP views on the delivery of alcohol interventions.

General practitioners' perceptions of chronic fatigue syndrome and beliefs about its management, compared with irritable bowel syndrome: qualitative study

OBJECTIVES

To compare general practitioners' perceptions of chronic fatigue syndrome and irritable bowel syndrome and to consider the implications of their perceptions for treatment.

DESIGN

Qualitative analysis of transcripts of group discussions.

PARTICIPANTS AND SETTING

A randomly selected sample of 46 general practitioners in England.

RESULTS

The participants tended to stereotype patients with chronic fatigue syndrome as having certain undesirable traits. This stereotyping was due to the lack of a precise bodily location; the reclassification of the syndrome over time; transgression of social roles, with patients seen as failing to conform to the work ethic and "sick role" and conflict between doctor and patient over causes and management. These factors led to difficulties for many general practitioners in managing patients with chronic fatigue syndrome. For both conditions many participants would not consider referral for mental health interventions, even though the doctors recognised social and psychological factors, because they were not familiar with the interventions or thought them unavailable or unnecessary.

CONCLUSIONS

Barriers to the effective clinical management of patients with irritable bowel syndrome and chronic fatigue syndrome are partly due to doctors' beliefs, which result in negative stereotyping of patients with chronic fatigue syndrome and the use of management strategies for both syndromes that may not take into account the best available evidence.

Lumbar radicular pain

BACKGROUND

Radicular pain is caused by irritation of the sensory root or dorsal root ganglion of a spinal nerve. The irritation causes ectopic nerve impulses perceived as pain in the distribution of the axon. The pathophysiology is more than just mass effect: it is a combination of compression sensitising the nerve root to mechanical stimulation, stretching, and a chemically mediated noncellular inflammatory reaction.

OBJECTIVE

This article discusses the clinical features, assessment and management of lumbar radicular pain (LRP).

DISCUSSION

Lumbar radicular pain is sharp, shooting or lancinating, and is typically felt as a narrow band of pain down the length of the leg, both superficially and deep. It may be associated with radiculopathy (objective sensory and/or motor dysfunction as a result of conduction block) and may coexist with spinal or somatic referred pain. In more than 50% of cases, LRP settles with simple analgesics. Significant and lasting pain relief can be achieved with transforaminal epidural steroid injection. Surgery is indicated for those patients with progressive neurological deficits or severe LRP refractory to conservative measures.

Interventions in chronic low back pain

BACKGROUND

Chronic low back pain presents a major challenge for general practitioners and is a significant drain on community resources. Patients often feel frustrated by modern medicine's apparent failure to validate their symptoms with a specific diagnosis and management plan.

OBJECTIVE

This article presents an evidence based guide to current interventions, including an algorithm for the interventional diagnostic workup of low back pain that has persisted beyond 3 months.

DISCUSSION

Modern imaging techniques rarely determine the cause of pain. The GP must look for 'red flag' clues in the history. Management of low back pain includes NSAIDs, simple injections of plain local anaesthetic without adrenalin or cortisone, referral to a masseuse, cortisone, physiotherapist and/or a musculoskeletal pain physician. Specific management includes medial branch and sacroiliac joint blocks, and radiofrequency neurotomy. Patients with long term pain may be referred to a psychologist for cognitive behavioural therapy.

Treat the patients' main dyspepsia complaint, not the ROME criteria

This pragmatic, primary care study by Meineche-Schmidt in patients with presumed acid-related uninvestigated dyspepsia showed that a standard dose of omeprazole 20 mg daily was significantly more effective than a placebo in treating their self-worded main dyspepsia complaint. As a higher dose of omeprazole 40 mg daily was not more effective, the standard dose should be used. In this study, 9% of the patients had sole reflux-like symptoms while the rest had other accompanying symptoms and would be considered to have dyspepsia. In fact, patients had on average more than five symptoms. Patients do not know that there is a controversy about whether to call their symptoms GERD or dyspepsia; they just know that they want to feel better. As no initial investigations were made, patients could have a variety of possible diagnoses such as gastroesophageal reflux disease, ulcer disease, or functional dyspepsia. The recent CADET-PE study showed that if patients had endoscopic abnormalities, these were findings such as esophagitis that would be appropriately treated with acid suppression. That study also reconfirmed that symptoms do not predict endoscopic findings and do not make a diagnosis. Thus, the approach suggested in this study to treat patients based on their main symptom complaint is practical and effective.

Back pain and opioid seeking behaviour

BACKGROUND

Back pain is a common presentation associated with opioid seeking behaviour.

OBJECTIVE

This case study provides general practitioners with a practical approach to seeing patients with chronic pain whom they suspect of opioid dependence and describes a framework for managing chronic pain and dependence within the general practice setting.

DISCUSSION

Back pain, with or without opioid dependence, is commonly encountered in general practice. General practitioners frequently find themselves caught between the desire to treat and relieve symptoms, and not wanting to cause or exacerbate dependence. Clear guidelines and access to support are often lacking.