Is it depression or is it bipolar depression?

This review is intended to guide primary care providers in differentiating patients with bipolar depression from those with unipolar depression and inform patient management. Up to 64% of clinical encounters for depression occur in primary care, with misdiagnosis of bipolar depression common in both primary care and psychiatry. Although bipolar disorder is characterized by manic, hypomanic, and depressive episodes, the most common and debilitating symptomatic presentation is depression. Misdiagnosis as unipolar depression is common, often resulting in mistreatment with an unopposed monoamine antidepressant. Antidepressants are often ineffective for treating bipolar depression and may cause detrimental consequences such as treatment-emergent hypomania/mania, rapid cycling, or increased suicidality. Factors that are suggestive of bipolar disorder versus unipolar depression include early-onset depression, frequent depressive episodes, family history of serious mental illness, hypomania/mania symptoms within the depressive episode, and nonresponse to antidepressants. Comorbid medical (e.g., cardiovascular disease, hypertension, obesity) and psychiatric (e.g., attention-deficit/hyperactivity disorder, anxiety disorder, personality disorders, and substance use disorder) conditions are common and contribute to premature mortality for patients with bipolar disorder compared with the general public. Cariprazine, fluoxetine/olanzapine, lurasidone, and quetiapine are approved to treat bipolar depression; only cariprazine and quetiapine are approved to treat both bipolar mania and depression. Primary care providers who can differentiate presenting symptoms of bipolar depression from unipolar depression and offer appropriate treatment options will optimize patient care in clinical practice. Relevant information for this review was identified through a multistep literature search of PubMed using the terms bipolar depression/bipolar disorder plus other relevant terms.

Developing a Clinical Decision Support Tool for Appropriate Antibiotic Prescribing in Australian General Practice: A Simulation Study.

Background. Inappropriate antibiotic prescribing can lead to antimicrobial resistance and drug side effects. Tools that assist general practitioners (GPs) in prescribing decisions may help to optimize prescribing. The aim of this study was to explore the use, acceptability, and feasibility of a clinical decision support (CDS) tool that incorporates evidence-based guidelines and consumer information that integrates with the electronic medical record (EMR). Methods. Eight GPs completed an interview and brief survey after participating in 2 simulated consultations. The survey consisted of demographic questions, perception of realism and representativeness of consultations, Post-Study System Usability Questionnaire, and System Usability Scale. Qualitative data were analyzed using framework analysis. Video data were reviewed, with length of consultation and time spent using the CDS tool documented. Results. Survey responses indicated that all GPs thought the consultations were "real" and representative of real-life consultations; 7 of 8 GPs were satisfied with usability of the tool. Key qualitative findings included that the tool assisted with clinical decision making and informed appropriate antibiotic prescribing. Accessibility and ease of use, including content (guideline and patient education resources), layout, and format, were key factors that determined whether GPs said that they would access the tool in everyday practice. Integration of the tool at multiple sites within the EMR facilitated access to guidelines and assisted in ensuring that the tool fit the clinical workflow. Conclusion. Our CDS tool was acceptable to GPs. Key features required for the tool were easy navigation, clear and useful guideline content, ability to fit into the clinical workflow, and incorporation into the EMR. Piloting of the tool in general practices to assess the impact and feasibility of use in real-world consultations will now be undertaken.

Imaging of the knee: Common acute presentations to general practice.

BACKGROUND: Knee pain is a common symptom in the community. There is a wide range of conditions that can cause pain. Identifying the type and severity of the condition is important for effective management. There are several guidelines for the appropriate imaging of patients presenting with knee pain. Presentation is generally divided into a post-traumatic group and those without known trauma (including arthritis). OBJECTIVE: The aim of this article is to discuss the approach to imaging of the knee with reference to Diagnostic Imaging Pathways and illustrate some of the conditions that may be encountered. DISCUSSION: The initial workup is typically done in general practice to determine which patients require referral for specialist management and which patients can be cared for in the community. Most cases presented in this article are patients referred from primary care to a metropolitan radiology practice during a six-month period, and they represent examples of some of the more common pathologies.

Type 2 diabetes and the medicine of exercise: The role of general practice in ensuring exercise is part of every patient's plan.

BACKGROUND: The benefit of exercise in the prevention and management of type 2 diabetes (T2D) has a strong evidence base, so it is important to ensure exercise is part of every patient's management plan. OBJECTIVE: This article reviews the evidence for exercise in T2D and the factors affecting a patient's willingness to commence and sustain enough exercise to gain benefit. The article offers tips about how to safely and effectively prescribe the 'medicine' of exercise for all, even the frailest patients; who to stabilise before an exercise program should begin; and how to use the skills of an accredited exercise physiologist (AEP) to deliver the best 'prescription' possible. DISCUSSION: General practitioners and their teams, along with other healthcare providers such as AEPs, can increase the amount of exercise medicine a patient receives. This is the case for those at risk of developing T2D, those with T2D and those with the many comorbidities associated with T2D.

Project Five Wishes: promoting advance directives in primary care.

BACKGROUND: Despite the widely known and well-established benefits of advance care planning, it is estimated that 15-30% of American adults have completed advance directives (ADs). Evidence suggests that the best place for advance care planning (ACP) is in primary care, but many barriers to this practice exist. LOCAL PROBLEM: Providers in a Northern Arizona private practice primary care clinic expressed frustration with their current ability and standard of care regarding ADs. Only 0.8% of their established adult patients had ADs. METHODS: Project Five Wishes was a 16-week trial designed to increase the number of ADs recorded at a Northern Arizona primary practice. The secondary purpose was to increase primary care provider knowledge, comfort, confidence, perceived importance, and frequency of discussions about ADs with patients. INTERVENTIONS: Interventions used in this project aimed to eliminate common barriers to ACP through a 30-minute presentation for providers and by integrating a user-friendly AD form into the office workflow. RESULTS: The number of ADs recorded increased by 25.4%. There were no statistically significant changes in the providers' reported knowledge, comfort, confidence, perceived importance, and frequency of discussions regarding ADs. CONCLUSIONS: The feasibly reproducible process used in Project Five Wishes was successful at increasing the number of patients with ADs in this 16-week trial and could lead to improvement in this area for other clinics as well.

General practice registrars' use of dermoscopy: Prevalence, associations and influence on diagnosis and confidence.

BACKGROUND AND OBJECTIVES: Dermoscopy increases accuracy for melanoma diagnosis by trained primary care physicians. We aimed to establish prevalence of dermatoscope use by general practice registrars, and identify factors associated with dermatoscope use and the implications of dermatoscope use for diagnosis and confidence in diagnosis. METHOD: This was a cross-sectional study nested within the Registrar Clinical Encounters in Training (ReCEnT) project, an ongoing multi-site cohort study of general practice registrars' consultations. The study was conducted during two six-monthly rounds of ReCEnT data collection in four regional training providers in 2014. RESULTS: Forty-nine per cent of registrars reported having dermoscopy training. Dermoscopy was used in 61% of consultations involving skin or pigmented lesion checks. Dermatoscope use changed provisional diagnosis in 22% of instances and increased diagnostic confidence in 55%. DISCUSSION: Dermoscopy is performed by general practice registrars in a modest proportion of skin and pigmented lesion checks. Its use influences registrars' diagnoses and increases their confidence in their diagnoses.

Pharmacogenomics in general practice: The time has come.

BACKGROUND: Patients respond to medications differently because of variations in the genes that determine medication exposure and medication response. OBJECTIVE: The aim of this review is to introduce pharmacogenomic testing and explain how to start using pharmacogenomic tests in general practice. DISCUSSION: Knowledge of the variants in pharmacogenomics is useful when prescribing a variety of medications. International guidelines have identified at least 15 genes for which testing can inform the prescribing of 30 different medications with good evidence of clinical benefit. Nonetheless, pharmacogenomic tests should not be used as the sole basis for prescribing decisions, and should be considered in the context of other relevant clinical and laboratory features. General practitioners can incorporate pharmacogenomic tests into their clinical practice for patients with medication-related problems or those who are likely to require medications for which pharmacogenomics can provide guidance.

Ecocardioscopia, periodo formativo necesario para médicos generalistas / Ecocardioscopy, a need of training period for general physicians

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Teaching patients with type 2 diabetes to self-administer insulin

BACKGROUND: Type 2 diabetes mellitus (T2DM) is a progressive chronic condition. Glucose-lowering medications are initiated, maximised and combined throughout the patient journey. Prescribing insulin is an integral part of managing T2DM. OBJECTIVE: The aim of this article is to provide practical guidance to assist commencement of insulin. DISCUSSION: Access to specialist diabetes care for insulin commencement varies considerably according to disease complexity, service type, setting and location. Delays in commencing insulin can result in the patient experiencing further glycaemic deterioration, increasing the risk of developing or worsening diabetes-related complications. Initiation of insulin in primary care can involve more than determining the type and dose of insulin in order to achieve optimal patient outcomes. The key to successfully teaching patients to self-administer insulin, and allowing them to master the steps involved, is to focus on 'why' rather than 'what' to do.

Point-of-Care Ultrasound in General Practice: A Systematic Review.

PURPOSE: Ultrasound examinations are currently being implemented in general practice. This study aimed to systematically review the literature on the training in and use of point-of-care ultrasound (POCUS) by general practitioners. METHODS: We followed the Cochrane guidelines for conduct and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting. We searched the databases MEDLINE (via PubMed), EMBASE, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials using the key words ultrasonography and general practice in combination and using thesaurus terms. Two reviewers independently screened articles for inclusion, extracted data, and assessed the quality of included studies using an established checklist. RESULTS: We included in our review a total of 51 full-text articles. POCUS was applied for a variety of purposes, with the majority of scans focused on abdominal and obstetric indications. The length of training programs varied from 2 to 320 hours. Competence in some types of focused ultrasound scans could be attained with only few hours of training. Focused POCUS scans were reported to have a higher diagnostic accuracy and be associated with less harm than more comprehensive scans or screening scans. The included studies were of a low quality, however, mainly because of issues with design and reporting. CONCLUSIONS: POCUS has the potential to be an important tool for the general practitioner and may possibly reduce health care costs. Future research should aim to assess the quality of ultrasound scans in broader groups of general practitioners, further explore how these clinicians should be trained, and evaluate the clinical course of patients who undergo scanning by general practitioners.

Emergency anaphylaxis protocols: A cross-sectional analysis of general practice surgeries and pharmacies in both the urban and rural setting in Ireland.

BACKGROUND: The incidence of anaphylaxis appears to be increasing worldwide with cases in the community outnumbering those in the hospital setting. General practice (GP) surgeries and pharmacies, based in the community, are often the first point of contact for many patients suffering from anaphylaxis. OBJECTIVES: To determine if studied GP surgeries and pharmacies have an anaphylaxis protocol on site and have access to an anaphylaxis kit; to explore GP's and pharmacists' personal experiences with management of anaphylaxis. METHODS: A cross-sectional, questionnaire-based study was performed examining anaphylaxis protocols in a sample of general practices and pharmacies from some counties in Ireland. This consisted of a sample from rural and urban settings. The study commenced in October 2014. RESULTS: Nineteen of 24 GPs (79%) and 9 (29%) pharmacies had an anaphylaxis protocol (P < 0.001). Twenty-four (100%) GP practices and 12 pharmacies (39%) surveyed had an anaphylaxis kit on site. Twelve GPs (50%) had treated a patient with anaphylaxis in the surgery while 8 (33%) had treated a patient in the community. One pharmacist (3%) had witnessed anaphylaxis in practice. Two pharmacies and one GP had been contacted by local businesses to alert them to a case of anaphylaxis. CONCLUSION: In contrast to national and international guidelines only 79% of GPs and 29% of pharmacies in this study from Ireland had an anaphylaxis protocol onsite.

Patient-directed reminders to improve preventive care in general practice for patients with type 2 diabetes: A proof of concept.

BACKGROUND AND OBJECTIVES: Preventive care in general practice is fundamental to managing the Australian diabetes epidemic. Recommended preventive care is nonetheless underperformed. The aim of this pilot study was to demonstrate proof of concept that pre-consultation patient-directed reminders could improve preventive care in general practice. METHOD: Over two weeks, four general practices used a special software tool to generate reminder sheets listing recommended checks for a subset of patients with type 2 diabetes mellitus (T2DM). The sheets were given to patients before their consultations. The number of checks performed was compared for patients who did and did not receive reminders. General practitioners (GPs) were interviewed about the reminders and chronic disease management. RESULTS: Patients who received reminders had more recommended checks performed than those who did not receive reminders. GPs found the reminders useful but suggested that broader system changes are required. DISCUSSION: Pre-consultation patient-directed reminders could potentially be an effective tool to increase preventive care for patients with T2DM in general practice.

[Study of the feasibility of spirometry in general practice]. / Étude de faisabilité de la spirométrie en médecine générale.

COPD is common but is under-diagnosed by general practitioners (GP). GP have a major role in the early diagnosis of this disease. GP could have access to spirometry. The aim of this study was to evaluate the quality and interpretation of spirometry performed by primary care residents following a short education session. Three residents were trained in spirometry for half a day. They then performed spirometry on all smokers over the age of 35 visiting five general practices. The results were reviewed blindly by an independent specialist pulmonologist to assess their quality and interpretation. Among 184 eligible patients, 89% agreed to participate and 66% (n=107) came for the second appointment. The pulmonologist evaluated the quality of spirometry as good in 72% of cases, of suboptimal but acceptable quality in 20% and of poor quality in 8%. Interpretation was accurate in 91% of tests. The Kappa concordance coefficient between GPs and the expert was 0.93. Airflow obstruction was detected in 17.5% of the screened subjects. The average time for a consultation with spirometry was 19minutes. The consultation dedicated to spirometry was well accepted by patients. A short training has to be structured to allow GPs to perform and interpret spirometry properly. This work needs to be extended to better assess reproducibility in cases of abnormal spirometry.

Could an online or digital aid facilitate discussions about sexual health with older Australians in general practice?

Background and objectives: Older patients want to discuss sexual health with general practitioners (GPs) but feel uncomfortable doing so, as do their GPs. Online and digital aids (ODAs) are used in other clinical contexts and could provide an effective tool to overcome this discomfort. The aim of this study was to explore health practitioners' views on the type of ODA that could be used to facilitate sexual health discussions between older patients (aged ≥60 years) and health practitioners. Methods: Thirty-seven interviews were conducted in Victoria, Australia, between March and June 2017. Participants comprised 15 GPs, 12 practice nurses or practice managers and 10 key informants (five in sexual health, five in ODAs). Results: Most ODAs currently available target younger populations. Checklists or self­service kiosks may provide effective means to facilitate sexual health discussions with older patients in primary care. Discussion: ODAs are acceptable and feasible to implement in younger populations but need testing with older patients. Health professionals need training to deal with sexual health matters arising from using such aids.

A historical account of the doctor's bag.

BACKGROUND: A household phrase of yesteryear was the doctor's 'little black bag'. Where did this phrase come from and how did it evolve? OBJECTIVE: The objective of the article is to outline the history of the medical bag and its contents, from early times to the present day, by using library research methodology. DISCUSSION: The first mention of a medical bag is in the Hippocratic Corpus around 350 BCE. This demonstrates that since ancient times, medical practitioners have carried some equipment and medications with them when they visited their patients, the exact contents changing over time.

Diagnostic accuracy of a pocket screening spirometer in diagnosing chronic obstructive pulmonary disease in general practice: a cross sectional validation study using tertiary care as a reference.

BACKGROUND: COPD-6™ is a lung function testing device for a rapid pre-spirometry testing to screen-out at-risk individuals not having COPD and indicating those at risk. The aim of this study was to validate COPD-6™ lung function testing (index test) in general practice in discriminating patients with COPD out of the population at risk - smokers/ex-smokers with no previous diagnosis of COPD, using measurements at tertiary care as reference standard. METHODS: Consecutive 227 subjects (115 women, 185 smokers/42 ex-smokers, ≥20 pack-years) with no previous diagnosis of COPD, aged 52.5 (SD 6.8) years from 26 general practitioners (GPs) were recruited, lung function tested with COPD-6™, referred to the tertiary institution for repeated COPD-6™ testing followed by spirometry with a bronchodilator (salbutamol), examination, and pulmonologist consultation for the diagnosis and severity of COPD. RESULTS: COPD was diagnosed in 43 subjects (18.9 %), with an AUC of 0.827 (95 % CI 0.769-0.875, P < 0.001) for the diagnosis of COPD when lung function was measured using COPD-6™ in GP's office with a specificity of 100 % (95 % CI, 97.95-100 %) but a very low sensitivity of 32.56 % (95 % CI, 20.49-47.48 %). Significant agreement for forced expiratory volume in 1 s measured at GP's office and at lung function lab was found (mean difference 0.01 L, p = 0.667) but not for other measured parameters (p < 0.001 for all). CONCLUSIONS: Our study results point out that active case finding in a population at risk for COPD should be instituted (almost 20 % of undiagnosed COPD). Based on our results lung function testing with COPD-6™ can substitute spirometry testing in cases where it is not readily available to the patient/physician taken into account that the traditional FEV1/FEV6 cutoff value of <0.7 is not the only criterion for diagnosis and/or further referral. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT01550679 Registered 28 September 2014, retrospectively registered.

Primum non nocere, o como trabajar con seguridad para el paciente / Primum Non Nocere or How to Create a Culture of Patient Safety

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Rolling Medical Practice: Ambulant Mobile Medical Care for Rural Areas.

We designed, constructed, and evaluated a mobile medical care vehicle called "Rollende Arztpraxis" (rolling medical practice, RMP) that delivers the full medical care of a general practitioner to increase medical care supply in rural areas. Six communities have been identified, where the RMP has been visited 501 times in 14 months. Two different schedules of stops and treatment times have been tested. We show that the RMP treated mainly elderly and multimorbid patients. An accompanying study showed high acceptance and satisfaction of treated patients and treating doctors. An economic evaluation of three different utilization models with three treatment modes each showed no financial sustainability. We show that ambulatory care in rural areas can be complemented by a mobile care unit, if legal and financial barriers can be overcome.