Assessing the impact of a gynaecomastia assessment and treatment infographic in primary care in Greater Manchester.

INTRODUCTION: Men with gynaecomastia are routinely referred to breast clinics, yet most do not require breast surgical intervention. The aim of this study was to assess the impact of a novel point-of-care gynaecomastia decision infographic in primary care on the assessment, management and referral practices to tertiary breast surgical services. METHODS: A study was carried out of male patient referrals from primary care in Greater Manchester to a tertiary breast centre between January and March in 2018-2020. Referral patterns were compared before and after the infographic went live in general practices in Greater Manchester in January 2020. Data were collected for gynaecomastia referrals, including aetiology, investigation and management. RESULTS: In total, 394 men were referred to a tertiary breast centre from 163 general practices, of which 271 (68.8%) had a diagnosis of gynaecomastia. Use of the decision infographic by primary healthcare providers was associated with a decrease in male breast referrals with gynaecomastia (79.6% to 62.0%). Fewer gynaecomastia patients were referred with a benign physiological or drug-related cause after implementation of the infographic (52.2% vs 41.8%). Only 10 (3.7%) patients with gynaecomastia underwent breast surgery during the study period. CONCLUSION: Implementation of a gynaecomastia infographic in primary care in Manchester was associated with a reduction in gynaecomastia referrals to secondary care. We hypothesise that implementation of the infographic into primary care nationally may potentially translate to hundreds of patients receiving more specialty-appropriate referrals, improving overall management of gynaecomastia. Further study is warranted to test this hypothesis.

The effects of policy actions to improve population dietary patterns and prevent diet-related non-communicable diseases: scoping review.

Poor diet generates a bigger non-communicable disease (NCD) burden than tobacco, alcohol and physical inactivity combined. We reviewed the potential effectiveness of policy actions to improve healthy food consumption and thus prevent NCDs. This scoping review focused on systematic and non-systematic reviews and categorised data using a seven-part framework: price, promotion, provision, composition, labelling, supply chain, trade/investment and multi-component interventions. We screened 1805 candidate publications and included 58 systematic and non-systematic reviews. Multi-component and price interventions appeared consistently powerful in improving healthy eating. Reformulation to reduce industrial trans fat intake also seemed very effective. Evidence on food supply chain, trade and investment studies was limited and merits further research. Food labelling and restrictions on provision or marketing of unhealthy foods were generally less effective with uncertain sustainability. Increasingly strong evidence is highlighting potentially powerful policies to improve diet and thus prevent NCDs, notably multi-component interventions, taxes, subsidies, elimination and perhaps trade agreements. The implications for policy makers are becoming clearer.

Obesity prevention strategies: could food or soda taxes improve health?

Evidence shows that one of the main causes for rising obesity rates is excessive consumption of sugar, which is due in large part to the high sugar content of most soda and juice drinks and junk foods. Worryingly, UK and global populations are consuming increasing amounts of sugary drinks and junk foods (high in salt, sugar and saturated fats). However, there is raised public awareness, and parents in particular want something to be done to curb the alarming rise in childhood obesity. Population-wide policies (i.e. taxation, regulation, legislation, reformulation) consistently achieve greater public health gains than interventions and strategies targeted at individuals. Junk food and soda taxes are supported by increasing evidence from empirical and modelling studies. The strongest evidence base is for a tax on sugar sweetened beverages, but in order to effectively reduce consumption, that taxation needs to be at least 20%. Empirical data from a number of countries which have implemented a duty on sugar or sugary drinks shows rapid, substantial benefits. In the UK, increasing evidence from recent scientific reports consistently support substantial reductions in sugar consumption through comprehensive strategies which include a tax. Furthermore, there is increasing public support for such measures. A sugar sweetened beverages tax will happen in the UK so the question is not 'If?' but 'When?' this tax will be implemented. And, crucially, which nation will get there first? England, Ireland, Scotland or Wales?

Unnecessary preoperative investigations: evaluation and cost analysis.

In keeping with national efforts to curb escalating health care costs, the necessity of multiple preoperative investigations was evaluated in 60 randomly selected ambulatory surgery patient records. Necessity for testing was assessed on clinical indications, and overall cost was calculated from the rates at both the local Department of Veterans Affairs Medical Center (VAMC) and a community hospital. Two thirds of the investigations were deemed to be inappropriate, with derived unnecessary average cost per patient of $47 and $80 for the VAMC and community hospital, respectively. Potential savings at the VAMC of $11,757.50 for the calendar year could have been realized. Education of staff and housestaff is crucial to changing obsolete practice habits. The quality and safety of care would not be compromised by limiting preoperative investigations to only those with clinical indications.

Postoperative pulmonary toxicity associated with mitomycin-C therapy.

As more patients survive cancer, and as more sophisticated multidrug antineoplastic protocols are developed, the chances of an anesthesiologist's coming into contact with patients who have been treated with such protocols are increasing. The anesthesiologist who must administer anesthesia to a patient who has had chemotherapy must be cognizant of the particular antineoplastic agents that have the potential for producing occult pulmonary dysfunction. Anesthetic management of these cases must be carefully planned and titrated to prevent further lung injury.

In vivo inactivation of tobramycin by piperacillin.

In vivo inactivation of aminoglycosides by antipseudomonal penicillins in patients with renal failure can be a significant problem when these drugs are used together in certain gram-negative infections. Our article illustrates the possible magnitude of this interaction and the resultant effect on aminoglycoside pharmacokinetic parameters. Penicillin concentrations remain relatively unaffected by this interaction. This article stresses the need for close monitoring of aminoglycoside concentrations when combined with antipseudomonal penicillins in this patient population.

Beyond career choice: the role of learning style analysis in residency training.

A recent article in this journal took an important step toward rethinking the utility of behavioural instruments designated as learning style tests (Jewett et al. 1987). The authors of that paper made much of a distinction between the terms 'learning style' and 'learning preference'. However, the results of their study do not seem to substantiate a marked difference between the function of the Rezler Learning Preference Inventory (LPI) and Kolb's Learning Style Inventory (LSI) with which it was contrasted. The most important aspect of their paper was that it rescued the concept of learning style analysis from the arena of career choice prediction at the undergraduate level and applied these ideas to doctors who had already made their specialty selections and were actively engaged in residency training. Clinical instructors in teaching institutions have, for the most part, little or no formal background in educational principles. For these individuals, an easily comprehensible model of resident-instructor psychology can be very useful on a daily basis. This article reviews the authors' experience with the LSI and describes their utilization of Kolb's Experimental Learning Model in the areas of resident counselling and residency curriculum design. The results of two recent studies are also presented in which learning style was examined as a predictor of success in residency, and teacher-resident learning style distributions were shown to exhibit parallel relationships at four different anaesthesiology residency training programmes.