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  Subjects -> HEALTH AND SAFETY (Total: 1292 journals)
    - CIVIL DEFENSE (18 journals)
    - DRUG ABUSE AND ALCOHOLISM (86 journals)
    - HEALTH AND SAFETY (521 journals)
    - HEALTH FACILITIES AND ADMINISTRATION (379 journals)
    - OCCUPATIONAL HEALTH AND SAFETY (106 journals)
    - PHYSICAL FITNESS AND HYGIENE (101 journals)
    - WOMEN'S HEALTH (81 journals)

HEALTH AND SAFETY (521 journals)                  1 2 3 | Last

Showing 1 - 200 of 203 Journals sorted alphabetically
16 de Abril     Open Access  
A Life in the Day     Hybrid Journal   (Followers: 9)
Acta Informatica Medica     Open Access   (Followers: 1)
Acta Scientiarum. Health Sciences     Open Access  
Adultspan Journal     Hybrid Journal  
Advances in Child Development and Behavior     Full-text available via subscription   (Followers: 10)
Advances in Public Health     Open Access   (Followers: 20)
African Health Sciences     Open Access   (Followers: 2)
African Journal for Physical, Health Education, Recreation and Dance     Full-text available via subscription   (Followers: 6)
African Journal of Health Professions Education     Open Access   (Followers: 4)
Afrimedic Journal     Open Access   (Followers: 2)
Air Quality, Atmosphere & Health     Hybrid Journal   (Followers: 3)
AJOB Primary Research     Partially Free   (Followers: 3)
American Journal of Family Therapy     Hybrid Journal   (Followers: 10)
American Journal of Health Economics     Full-text available via subscription   (Followers: 13)
American Journal of Health Education     Hybrid Journal   (Followers: 25)
American Journal of Health Promotion     Hybrid Journal   (Followers: 22)
American Journal of Health Studies     Full-text available via subscription   (Followers: 8)
American Journal of Preventive Medicine     Hybrid Journal   (Followers: 21)
American Journal of Public Health     Full-text available via subscription   (Followers: 179)
American Journal of Public Health Research     Open Access   (Followers: 27)
American Medical Writers Association Journal     Full-text available via subscription   (Followers: 2)
Analytic Methods in Accident Research     Hybrid Journal   (Followers: 2)
Annali dell'Istituto Superiore di Sanità     Open Access  
Annals of Global Health     Open Access   (Followers: 8)
Annals of Health Law     Open Access   (Followers: 3)
Annals of Tropical Medicine and Public Health     Open Access   (Followers: 15)
Applied Biosafety     Hybrid Journal  
Applied Research In Health And Social Sciences : Interface And Interaction     Open Access  
Archives of Medicine and Health Sciences     Open Access   (Followers: 2)
Asia Pacific Journal of Counselling and Psychotherapy     Hybrid Journal   (Followers: 8)
Asia Pacific Journal of Health Management     Full-text available via subscription   (Followers: 2)
Asia-Pacific Journal of Public Health     Hybrid Journal   (Followers: 8)
Asian Journal of Gambling Issues and Public Health     Open Access   (Followers: 3)
Association of Schools of Allied Health Professions     Full-text available via subscription   (Followers: 5)
Atención Primaria     Open Access   (Followers: 1)
Australasian Journal of Paramedicine     Open Access   (Followers: 2)
Australian Advanced Aesthetics     Full-text available via subscription   (Followers: 4)
Australian Family Physician     Full-text available via subscription   (Followers: 3)
Australian Indigenous HealthBulletin     Free   (Followers: 6)
Autism & Developmental Language Impairments     Open Access   (Followers: 1)
Behavioral Healthcare     Full-text available via subscription   (Followers: 4)
Best Practices in Mental Health     Full-text available via subscription   (Followers: 6)
Bijzijn     Hybrid Journal   (Followers: 2)
Bijzijn XL     Hybrid Journal   (Followers: 1)
Biomedical Safety & Standards     Full-text available via subscription   (Followers: 9)
BLDE University Journal of Health Sciences     Open Access  
BMC Oral Health     Open Access   (Followers: 5)
BMC Pregnancy and Childbirth     Open Access   (Followers: 18)
BMJ Simulation & Technology Enhanced Learning     Full-text available via subscription   (Followers: 7)
Brazilian Journal of Medicine and Human Health     Open Access  
Buletin Penelitian Kesehatan     Open Access   (Followers: 2)
Buletin Penelitian Sistem Kesehatan     Open Access  
Bulletin of the World Health Organization     Open Access   (Followers: 15)
Cadernos de Educação, Saúde e Fisioterapia     Open Access   (Followers: 1)
Cadernos Saúde Coletiva     Open Access   (Followers: 1)
Canadian Family Physician     Partially Free   (Followers: 11)
Canadian Journal of Community Mental Health     Full-text available via subscription   (Followers: 10)
Canadian Journal of Human Sexuality     Hybrid Journal   (Followers: 1)
Canadian Journal of Public Health     Full-text available via subscription   (Followers: 18)
Case Reports in Women's Health     Open Access   (Followers: 2)
Case Studies in Fire Safety     Open Access   (Followers: 11)
Central Asian Journal of Global Health     Open Access   (Followers: 2)
Central European Journal of Public Health     Full-text available via subscription   (Followers: 4)
CES Medicina     Open Access  
Child Abuse Research in South Africa     Full-text available via subscription   (Followers: 1)
Child's Nervous System     Hybrid Journal  
Childhood Obesity and Nutrition     Open Access   (Followers: 10)
Children     Open Access   (Followers: 2)
CHRISMED Journal of Health and Research     Open Access  
Christian Journal for Global Health     Open Access  
Ciência & Saúde Coletiva     Open Access   (Followers: 2)
Ciencia y Cuidado     Open Access  
Ciencia, Tecnología y Salud     Open Access  
ClinicoEconomics and Outcomes Research     Open Access   (Followers: 1)
CME     Hybrid Journal   (Followers: 1)
CoDAS     Open Access  
Community Health     Open Access   (Followers: 1)
Conflict and Health     Open Access   (Followers: 8)
Curare     Open Access  
Current Opinion in Behavioral Sciences     Hybrid Journal   (Followers: 1)
Day Surgery Australia     Full-text available via subscription   (Followers: 2)
Digital Health     Open Access  
Dramatherapy     Hybrid Journal   (Followers: 2)
Drogues, santé et société     Full-text available via subscription  
Duazary     Open Access   (Followers: 1)
Early Childhood Research Quarterly     Hybrid Journal   (Followers: 13)
East African Journal of Public Health     Full-text available via subscription   (Followers: 3)
Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity     Hybrid Journal   (Followers: 16)
EcoHealth     Hybrid Journal   (Followers: 3)
Education for Health     Open Access   (Followers: 4)
electronic Journal of Health Informatics     Open Access   (Followers: 4)
ElectronicHealthcare     Full-text available via subscription   (Followers: 3)
Elsevier Ergonomics Book Series     Full-text available via subscription   (Followers: 5)
Emergency Services SA     Full-text available via subscription   (Followers: 2)
Ensaios e Ciência: Ciências Biológicas, Agrárias e da Saúde     Open Access  
Environmental Disease     Open Access  
Environmental Sciences Europe     Open Access   (Followers: 1)
Epidemics     Open Access   (Followers: 3)
Epidemiologic Perspectives & Innovations     Open Access   (Followers: 3)
Epidemiology, Biostatistics and Public Health     Open Access   (Followers: 18)
Ethics, Medicine and Public Health     Full-text available via subscription  
Ethiopian Journal of Health Development     Open Access   (Followers: 8)
Ethiopian Journal of Health Sciences     Open Access   (Followers: 7)
Ethnicity & Health     Hybrid Journal   (Followers: 13)
European Journal of Investigation in Health, Psychology and Education     Open Access   (Followers: 1)
European Medical, Health and Pharmaceutical Journal     Open Access  
Evaluation & the Health Professions     Hybrid Journal   (Followers: 8)
Evidence-based Medicine & Public Health     Open Access   (Followers: 4)
Evidência - Ciência e Biotecnologia - Interdisciplinar     Open Access  
Expressa Extensão     Open Access  
Face à face     Open Access   (Followers: 1)
Families, Systems, & Health     Full-text available via subscription   (Followers: 8)
Family & Community Health     Partially Free   (Followers: 12)
Family Medicine and Community Health     Open Access   (Followers: 3)
Family Relations     Partially Free   (Followers: 11)
Fatigue : Biomedicine, Health & Behavior     Hybrid Journal   (Followers: 1)
Food and Public Health     Open Access   (Followers: 10)
Frontiers in Public Health     Open Access   (Followers: 8)
Gaceta Sanitaria     Open Access   (Followers: 3)
Galen Medical Journal     Open Access  
Geospatial Health     Open Access  
Gesundheitsökonomie & Qualitätsmanagement     Hybrid Journal   (Followers: 11)
Giornale Italiano di Health Technology Assessment     Full-text available via subscription  
Global Health : Science and Practice     Open Access   (Followers: 4)
Global Health Promotion     Hybrid Journal   (Followers: 15)
Global Journal of Health Science     Open Access   (Followers: 7)
Global Journal of Public Health     Open Access   (Followers: 9)
Global Medical & Health Communication     Open Access  
Globalization and Health     Open Access   (Followers: 5)
Hacia la Promoción de la Salud     Open Access  
Hastings Center Report     Hybrid Journal   (Followers: 4)
HEADline     Hybrid Journal  
Health & Place     Hybrid Journal   (Followers: 14)
Health & Justice     Open Access   (Followers: 5)
Health : An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine     Hybrid Journal   (Followers: 7)
Health and Human Rights     Free   (Followers: 8)
Health and Social Care Chaplaincy     Hybrid Journal   (Followers: 9)
Health and Social Work     Hybrid Journal   (Followers: 46)
Health Behavior and Policy Review     Full-text available via subscription   (Followers: 1)
Health Care Analysis     Hybrid Journal   (Followers: 11)
Health Inform     Full-text available via subscription  
Health Information Management Journal     Hybrid Journal   (Followers: 10)
Health Issues     Full-text available via subscription   (Followers: 1)
Health Policy     Hybrid Journal   (Followers: 32)
Health Policy and Technology     Hybrid Journal  
Health Professional Student Journal     Open Access   (Followers: 1)
Health Promotion International     Hybrid Journal   (Followers: 20)
Health Promotion Journal of Australia : Official Journal of Australian Association of Health Promotion Professionals     Full-text available via subscription   (Followers: 10)
Health Promotion Practice     Hybrid Journal   (Followers: 15)
Health Prospect     Open Access   (Followers: 1)
Health Psychology     Full-text available via subscription   (Followers: 47)
Health Psychology Research     Open Access   (Followers: 18)
Health Psychology Review     Hybrid Journal   (Followers: 39)
Health Renaissance     Open Access  
Health Research Policy and Systems     Open Access   (Followers: 9)
Health SA Gesondheid     Open Access   (Followers: 2)
Health Science Reports     Open Access  
Health Services Insights     Open Access   (Followers: 1)
Health Systems     Hybrid Journal   (Followers: 2)
Health Voices     Full-text available via subscription  
Health, Culture and Society     Open Access   (Followers: 10)
Health, Risk & Society     Hybrid Journal   (Followers: 10)
Healthcare     Open Access   (Followers: 1)
Healthcare in Low-resource Settings     Open Access   (Followers: 1)
Healthcare Quarterly     Full-text available via subscription   (Followers: 8)
HERD : Health Environments Research & Design Journal     Full-text available via subscription  
Highland Medical Research Journal     Full-text available via subscription  
Hispanic Health Care International     Full-text available via subscription  
HIV & AIDS Review     Full-text available via subscription   (Followers: 10)
Home Health Care Services Quarterly     Hybrid Journal   (Followers: 5)
Hong Kong Journal of Social Work, The     Hybrid Journal   (Followers: 2)
Hospitals & Health Networks     Free   (Followers: 2)
IEEE Journal of Translational Engineering in Health and Medicine     Open Access   (Followers: 3)
IMTU Medical Journal     Full-text available via subscription  
Indian Journal of Health Sciences     Open Access   (Followers: 1)
Inmanencia. Revista del Hospital Interzonal General de Agudos (HIGA) Eva Perón     Open Access  
Innovative Journal of Medical and Health Sciences     Open Access  
Institute for Security Studies Papers     Full-text available via subscription   (Followers: 6)
interactive Journal of Medical Research     Open Access  
International Health     Hybrid Journal   (Followers: 4)
International Journal for Equity in Health     Open Access   (Followers: 7)
International Journal for Quality in Health Care     Hybrid Journal   (Followers: 32)
International Journal of Applied Behavioral Sciences     Open Access   (Followers: 1)
International Journal of Behavioural and Healthcare Research     Hybrid Journal   (Followers: 7)
International Journal of Circumpolar Health     Open Access   (Followers: 1)
International Journal of Community Medicine and Public Health     Open Access   (Followers: 5)
International Journal of E-Health and Medical Communications     Full-text available via subscription   (Followers: 2)
International Journal of Environmental Research and Public Health     Open Access   (Followers: 19)
International Journal of Evidence-Based Healthcare     Hybrid Journal   (Followers: 8)
International Journal of Food Safety, Nutrition and Public Health     Hybrid Journal   (Followers: 13)
International Journal of Health & Allied Sciences     Open Access   (Followers: 1)
International Journal of Health Care Quality Assurance     Hybrid Journal   (Followers: 7)
International Journal of Health Geographics     Open Access   (Followers: 6)
International Journal of Health Policy and Management     Open Access   (Followers: 2)
International Journal of Health Professions     Open Access   (Followers: 2)
International Journal of Health Promotion and Education     Hybrid Journal   (Followers: 12)
International Journal of Health Research     Open Access   (Followers: 4)
International Journal of Health Sciences Education     Open Access   (Followers: 2)
International Journal of Health Services     Full-text available via subscription   (Followers: 9)

        1 2 3 | Last

Journal Cover Australian Family Physician
  [SJR: 0.364]   [H-I: 31]   [3 followers]  Follow
    
   Full-text available via subscription Subscription journal
   ISSN (Print) 0300-8495
   Published by RMIT Publishing Homepage  [403 journals]
  • Volume 46 Issue 6 - Can research that is not intended or unlikely to be
           published be considered ethical'
    • Abstract: Barton, Christopher; Tam, Chun Wah Michael; Abbott, Penelope; Hall, Sally; Liaw, Siaw-Teng
      Background: For research to be ethically acceptable, the potential benefits must justify any risks involved for participants. Dissemination of research findings through publication is one way of creating benefit, but not all researchers intend to publish their research. Other factors, such as lack of size or representativeness, generalisability or innovativeness, or negative findings mean the research is unlikely to be published in a peer-reviewed medical journal.

      Objectives: This paper discusses ethical considerations in research where peer-reviewed publication is not intended or unlikely.

      Discussion: Proposing research that is not intended or unlikely to be published in a peer-reviewed journal does not preclude it from being considered ethical. Additional benefits of such projects may include professional development of investigators, pilot data collection leading to more definitive studies, or developing collaborations with research users that increase relevance and improve utility of findings.

      PubDate: Tue, 6 Jun 2017 12:05:18 GMT
       
  • Volume 46 Issue 6 - Guidelines and systematic reviews: Sizing up
           guidelines in general practice
    • Abstract: van Driel, Mieke L; Spurling, Geoffrey
      This article is the second in a series on general practice research in Australia. The series explores strategies to strengthen general practice research and further develop the evidence base for primary care.

      PubDate: Tue, 6 Jun 2017 12:02:10 GMT
       
  • Volume 46 Issue 6 - Procedural skills of Australian general practice
           registrars: A cross-sectional analysis
    • Abstract: Aghajafari, Fariba; Tapley, Amanda; Sylvester, Steve; Davey, Andrew R; Morgan, Simon; Henderson, Kim M; van Driel, Mieke L; Spike, Neil A; Kerr, Rohan H; Catzikiris, Nigel F; Mulquiney, Katie J; Magin, Parker J
      Background and objectives: Procedural skills are an essential component of general practice vocational training. The aim of this study was to investigate the type, frequency and rural or urban associations of procedures performed by general practice registrars, and to establish levels of concordance of procedures performed with a core list of recommended procedural skills in general practice training.

      Methods: A cross-sectional analysis of a cohort study of registrars' consultations between 2010 and 2016 was undertaken. Registrars record 60 consecutive consultations during each six-month training term. The outcome was any procedure performed.

      Results: In 182,782 consultations, 19,411 procedures were performed. Procedures (except Papanicolaou [Pap] tests) were performed more often in rural than urban areas. Registrars commonly sought help from supervisors for more complex procedures. The majority of procedures recommended as essential in registrar training were infrequently performed.

      Discussion: Registrars have low exposure to many relevant clinical procedures. There may be a need for greater use of laboratory-based training and/or to review the expectations of the scope of procedural skills in general practice.

      PubDate: Tue, 6 Jun 2017 11:59:19 GMT
       
  • Volume 46 Issue 6 - Who do Australian general practitioners refer to
           physiotherapy'
    • Abstract: Dennis, Sarah; Watts, Ian; Pan, Ying; Britt, Helena
      Background and objectives: Physiotherapy plays an important role in the health of many Australians. The aims of this study were to assess changes in the rate of general practitioner (GP) referral to physiotherapists in Australia from 1998 to 2014, and to determine patient characteristics associated with increased likelihood of such referral.

      Method: Secondary analysis was undertaken of data from the Bettering the Evaluation and Care of Health program using weighted encounter data years 1998-99 to 2014-15 inclusive.

      Results: The rate of GP referral to physiotherapists remained steady until 2010, when referrals increased. Patients were more likely to be referred to physiotherapy if they had a Department of Veterans' Affairs card; did not have a Health Care Card; were female aged 45-64 years; or male aged 25-44 years. Musculoskeletal problems accounted for 80% of referrals, but only 6.8% of all musculoskeletal problems managed were referred.

      Discussion: Allied health Medicare Benefits Schedule item numbers have increased referrals to physiotherapy. However, there are some population groups who are not referred but might benefit from physiotherapy.

      PubDate: Tue, 6 Jun 2017 11:56:21 GMT
       
  • Volume 46 Issue 6 - Assessment and management of asthma and chronic
           obstructive pulmonary disease in Australian general practice
    • Abstract: Reddel, Helen K; Valenti, Lisa; Easton, Kylie L; Gordon, Julie; Bayram, Clare; Miller, Graeme C
      Background: Dispensing data suggest potential issues with the quality use of medicines for airways disease.

      Objective: The objective of this article was to describe the management of asthma and chronic obstructive pulmonary disease (COPD) in general practice, and investigate the appropriateness of prescribing.

      Method: The method used for this study consisted of a national cross‑sectional survey of 91 Australian general practitioners (GPs) participating in the Bettering the Evaluation and Care of Health (BEACH) program.

      Results: Data were available for 2589 patients (288 asthma; 135 COPD). For the patients with asthma, GPs classified asthma as well controlled in 76.4%; 54.3% were prescribed inhaled corticosteroids (ICS), mostly (84.9%) as combination therapy, and mostly at moderate-high dose; only 26.3% had a written action plan. GPs classified COPD as mild for 42.9%. Most patients with COPD (60.9%) were prescribed combination ICS therapy and 36.7% were prescribed triple therapy.

      Discussion: There were substantial differences between guideline-based and GP-recorded assessment and prescription for asthma and COPD. Further research is needed to improve care and optimise patient outcomes with scarce health resources.

      PubDate: Tue, 6 Jun 2017 11:54:39 GMT
       
  • Volume 46 Issue 6 - Up, up and away: The growth of after-hours MBS claims
    • Abstract: de Graaff, Barbara; Nelson, Mark; Neil, Amanda
      Background and objective: Media reports suggest that growth in urgent, after-hours Medicare Benefits Schedule (MBS) claims has coincided with an increasing number of after-hours medical deputising services (AHMDSs). This article assesses these claims in the context of an increasing presence of AHMDSs.

      Method: Retrospective analysis of MBS claims data for general practitioner (GP) after-hours items from 2010-11 to 2015-16 was conducted. The Tasmanian experience is presented as a case study.

      Results: The number of claims was greatest for MBS item number 597 (urgent, sociable after-hours consultations), increasing by 170% over the study period. For jurisdictions with dates identified for the introduction of AHMDSs, dramatic growth in per capita claims were observed: 1270% for the Australian Capital Territory, 485% for Tasmania and 150% for the Northern Territory. For Tasmania, no decrease in emergency department presentations was observed.

      Discussion: Rapid increases in after-hours claims for MBS item number 597 have coincided with the introduction of AHMDSs in three jurisdictions. The impact on patient outcomes and equitable resource distribution requires attention.

      PubDate: Tue, 6 Jun 2017 11:52:14 GMT
       
  • Volume 46 Issue 6 - Painful pustular dactylitis in an elderly patient
    • Abstract: Teixeira, Jose Tiago; Afonso, Carina; Machado, Maria Bernardete; Morais, Paulo
      A man, 74 years of age, presented with dactylitis on the first, second and fourth digits of his left hand, characterised by glossy erythema, oedema, pustules and yellowish scales. Additionally, there was onychodystrophy, subungual hyperkeratosis, almost complete onycholysis and pustules on the nail bed. The lesions first appeared two months ago and have been progressively worsening since, spreading proximally. There were no similar lesions and no evidence of psoriasis on full‑skin examination. The patient also noted functional incapacity of the affected digits, along with pain to the touch, but denied hand trauma prior to the appearance of the lesions.

      PubDate: Tue, 6 Jun 2017 09:49:35 GMT
       
  • Volume 46 Issue 6 - Obesity and weight management at menopause
    • Abstract: Proietto, Joseph
      Background: Many women report gaining weight as they transition through menopause. For most, the weight gain is modest and can be reduced with a conscious effort to limit energy intake and increase energy expenditure. However, many women who are already overweight and obese will gain more weight as they approach menopause.

      Objectives: The aims of this paper are to explain the reasons for menopausal weight gain and to detail a method for achieving and sustaining a substantial weight loss.

      Discussion: Weight gain during menopause is predominantly due to a reduction in spontaneous activity. For women who are lean, advice about controlling energy intake and increasing physical activity may be all that is required to prevent weight gain. For women who are overweight and obese rapid weight loss is best achieved with the help of a very low energy diet. This must be followed by lifelong behaviour modification with or without the help of hunger-suppressing pharmacotherapy.

      PubDate: Tue, 6 Jun 2017 09:40:32 GMT
       
  • Volume 46 Issue 6 - Perimenopausal contraception: A practice-based
           approach
    • Abstract: Bateson, Deborah; McNamee, Kathleen
      Background: Women who are perimenopausal are at risk of unintended pregnancy despite relatively low fertility at this stage. Contraceptive choice can be limited by increased comorbidities, but the UK Medical Eligibility Criteria (UKMEC) system provides a framework for safe prescribing.

      Objectives: This article provides evidence-based guidance on contraceptive options, and information to support decision-making about stopping contraception at menopause.

      Discussion: Contraceptive choice is determined by several factors, including medical eligibility, side effects and risks, non-contraceptive benefits, cost and personal preference. Long-acting reversible contraceptives (LARCs) are an effective, acceptable and safe choice for many women. For women aged > =50 years who are using a non-hormonal method, contraception is recommended until after 12 months of amenorrhoea, or 24 months if they are aged < 50 years. Switching from a combined hormonal contraceptive or depot injection to an alternative progestogen‑only or non-hormonal method is advised in women aged > 50 years; serial follicle-stimulating hormone (FSH) levels can guide method cessation given amenorrhoea is not a reliable indicator of menopause in this context.

      PubDate: Fri, 2 Jun 2017 21:13:38 GMT
       
  • Volume 46 Issue 6 - Incidental adrenal masses - a primary care approach
    • Abstract: Gendy, Rasha; Rashid, Prem
      Background: The common use of cross-sectional imaging for the investigation of abdominal and thoracic illness has resulted in the rise of the incidentally identified adrenal mass, or incidentaloma, which presents a diagnostic and management dilemma for the primary care physician.

      Objective: This article provides a framework for the investigation and management of incidental adrenal masses.

      Discussion: Adrenal incidentalomas are found in approximately 3-4% of abdominal computed tomography (CT) scans. It is important to evaluate these incidental adrenal lesions to determine what treatment, if any, is needed and when specialist referral may be necessary. In particular, incidentalomas must be evaluated in regard to their functional status and malignant potential, as lesions can range from being indolent, benign and non-functioning tumours that can simply be observed, to aggressive and hormonally active malignant lesions that require urgent surgical intervention.

      PubDate: Fri, 2 Jun 2017 21:13:38 GMT
       
  • Volume 46 Issue 6 - Bilateral vision loss in a child recently diagnosed
           with type 1 diabetes mellitus
    • Abstract: O'Day, Roderick Francis Justin; Rocke, John Ross; Tennakoon, Janaka; Sheth, Shivanand; Raj, Christolyn
      A boy, 12 years of age, was referred to the ophthalmology department in the state capital tertiary-referral paediatric hospital with bilateral vision loss and dull red reflexes. Two weeks earlier, he was diagnosed with type 1 diabetes mellitus (T1DM) after presenting to a regional centre base hospital, 150 km outside the nearest capital city, with a four-day history of lethargy, vomiting, polyuria and polydipsia. He was found to be in diabetic ketoacidosis (DKA), with a pH of 6.8, blood glucose of 37.3 mmol/L and glycated haemoglobin (HbA1c) of 9.2%. He had no significant past medical history, no regular medications and no known allergies, and was discharged after 48 hours on a regimen of insulin aspart 30 units twice daily.

      PubDate: Fri, 2 Jun 2017 21:13:38 GMT
       
  • Volume 46 Issue 6 - Measuring and managing complexity
    • Abstract: Samuel, Sophia
      PubDate: Fri, 2 Jun 2017 21:13:38 GMT
       
  • Volume 46 Issue 6 - Travelling safely to places at high altitude -
           Understanding and preventing altitude illness
    • Abstract: Parise, Ivan
      Background: Greater numbers of people are travelling to places at high altitude each year. Altitude illness is common in places at high altitude and may be life-threatening. General practitioners (GPs) are best placed to provide evidence-based advice to keep travellers well informed of the possible risks they may encounter in places at high altitude.

      Objectives: The aim of this article is to review knowledge on altitude illness in order to help GPs assist patients to travel safely to places at high altitude.

      Discussion: Acclimatisation to high altitude is a complex process and when inadequate leads to the pathological changes of altitude illness, including high-altitude headache, cerebral oedema, pulmonary oedema and acute mountain sickness. Higher ascent, faster rate of ascent and a previous history of altitude illness increase the risk of altitude illness. Acetazolamide and other medications used to prevent altitude illness are discussed in detail, including the finding that inhaled budesonide may prevent altitude illness.

      PubDate: Fri, 2 Jun 2017 21:13:38 GMT
       
  • Volume 46 Issue 6 - Keeping an eye on syphilis
    • Abstract: Ong, Daini; Bhardwaj, Gaurav; Ong, Jason; Chen, Marcus; Lim, Lyndell L
      Background and objective: The objective of this article was to alert general practitioners (GPs) to the increase in ocular syphilis in the context of a worsening epidemic of syphilis among men who have sex with men (MSM).

      Method: This study used a retrospective case review of ocular syphilis cases that presented to the Royal Victorian Eye and Ear Hospital from January 2015 to August 2016.

      Results: Twelve patients (19 eyes) were identified, including 11 males. The mean age was 35 years, and seven men were identified as MSM. Two men were diagnosed with human immunodeficiency virus (HIV) infection at presentation. Blurred vision (n = 10) and/or floaters (n = 9) were the most common presenting symptoms. All patients had uveitis as the manifestation of the ocular involvement; however, redness and pain were not universally reported.

      Discussion: GPs should be alert to the possibility of ocular syphilis at the time of syphilis diagnosis, particularly among MSM. Urgent ophthalmic referral is required if the patient is found to have new onset visual symptoms.

      PubDate: Fri, 2 Jun 2017 21:13:38 GMT
       
  • Volume 46 Issue 6 - Clinical challenge
    • PubDate: Fri, 2 Jun 2017 21:13:38 GMT
       
  • Volume 46 Issue 6 - Premature ovarian insufficiency in general practice:
           Meeting the needs of women
    • Abstract: Nguyen, Hanh H; Milat, Frances; Vincent, Amanda
      Background: Premature ovarian insufficiency (POI), defined as amenorrhoea due to the loss of ovarian function before 40 years of age, can occur spontaneously or be secondary to medical therapies. POI is associated with cardiovascular morbidity, osteoporosis and premature mortality. Women with POI present in primary care with menstrual disturbance, menopausal symptoms, infertility and, often, significant psychosocial issues. General practitioners play an important role in the evaluation and long-term management of women with POI.

      Objective: This article examines the diagnostic and management issues when providing care for women with POI in the primary care setting.

      Discussion: Diagnosis of POI requires follicle-stimulating hormone (FSH) levels in the menopausal range on two occasions, at least four to six weeks apart in a woman aged < 40 years, after more than four months of amenorrhoea or menstrual irregularity. The diagnosis is often distressing and women are likely to require psychological support. Hormone replacement therapy, unless contraindicated, is required and should be continued until the age of natural menopause. Contraception is required if pregnancy is not wanted, and multidisciplinary management is necessary.

      PubDate: Fri, 2 Jun 2017 21:13:38 GMT
       
  • Volume 46 Issue 5 - General practitioners and school psychologists: An
           underused collaboration
    • Abstract: Burns, John R; Wong, Kevin
      Background: General Practitioners (GPs) play a vital role in the management of the social, emotional and behavioural health of children and adolescents. Best practice usually requires collaboration with a broad range of other medical and allied health professionals, to bring about optimal outcomes for patients and their family.

      Objectives: This article describes the specific role of a school psychologist and outlines various ways that GPs and school psychologists can collaborate in the assessment and management of school‑aged patients.

      Discussion: Given the importance of school in the social and emotional development of children and adolescents, school psychologists should be considered a valuable partner for GPs when caring for young people.

      PubDate: Mon, 8 May 2017 19:11:53 GMT
       
  • Volume 46 Issue 5 - Clinical challenge
    • PubDate: Mon, 8 May 2017 19:11:53 GMT
       
  • Volume 46 Issue 5 - Measuring general practice activity in Australia: A
           brief history
    • Abstract: Britt, Helena; Miller, Graeme C
      Health services research on general practice that aimed to improve the function of practice and quality of care dates from the seminal ethnographic study of English general practice by Australian general practitioner (GP) Joseph Collings in 1950.1 This remarkable 30-page report published in The Lancet shook British general practice to its foundations and triggered the formation of the Royal College of General Practitioners (RCGP), the world's first general practice college, and subsequently The Royal Australian College of General Practitioners (RACGP).

      PubDate: Mon, 8 May 2017 19:11:53 GMT
       
  • Volume 46 Issue 5 - General practitioners' knowledge about use of topical
           corticosteroids in paediatric atopic dermatitis in Australia
    • Abstract: Smith, Saxon D; Harris, Victoria; Lee, Andrew; Blaszczynski, Alex; Fischer, Gayle
      Background and objective: Topical corticosteroids are the standard of care in paediatric atopic dermatitis (pAD). However, messages that overstress possible side effects can have a negative impact on perceptions of safety and contribute to treatment non-adherence. The aim of this study was to assess general practitioners' (GPs') perception of the safety of topical corticosteroids in pAD treatment.

      Methods: Australian GPs participating in continuing professional development programs were assessed before an education session on pAD. Responses were recorded via an electronic survey.

      Results: A total of 257 GPs were surveyed. More than one-third (40.7%) of the GPs instructed parents to apply topical corticosteroids for two weeks or less. Nearly half (47.7%) instructed parents to apply topical corticosteroids sparingly or with the smallest amount possible. Furthermore, nearly one-third (30.2%) reported skin atrophy as the most common side effect of topical corticosteroids.

      Discussion: Advice to patients given by Australian GPs may carry unintentional risk messages contributing to treatment non‑adherence. Evidence-based information on the safety of topical corticosteroids is needed to empower GPs to improve treatment outcomes in pAD.

      PubDate: Mon, 8 May 2017 19:11:53 GMT
       
  • Volume 46 Issue 5 - GPs' perspectives on prescribing intrauterine
           contraceptive devices
    • Abstract: Lodge, Gabrielle; Sanci, Lena; Temple-Smith, Meredith
      Background and objective: Globally, 14% of women use intrauterine contraceptive devices (IUCDs) for prevention of unplanned pregnancy. In Australia, the use of IUCDs is negligible at
      PubDate: Mon, 8 May 2017 19:11:53 GMT
       
  • Volume 46 Issue 5 - Actual availability of appointments at general
           practices in regional New South Wales, Australia
    • Abstract: Bradbury, Joanne; Nancarrow, Susan; Avila, Cathy; Pit, Sabrina; Potts, Ruth; Doran, Frances; Freed, Gary
      Background and objective: There is limited data to inform policy about the availability and costs of primary healthcare at the local level. The objective of this article was to determine the appointment availability and out-ofpocket costs for patients presenting with non‑urgent conditions to general practices in a regional setting.

      Method: A cross-sectional, census study included all 184 general practices across 12 local government areas in northern New South Wales. Practices were telephoned in a randomised sequence on weekday mornings by a researcher.

      Results: Twenty-two practices were excluded from the study as these were specialised‑only services; therefore, the sample size was n = 162. The rate of same-day appointment availability was 47.5% (n = 77/162; range: 11-63%), and bulk-billing availability was 21% (range: 0-50%). The mean out-of-pocket cost was $29.98 (range: $12.95-60.30).

      Discussion: Availability of primary healthcare and bulk billing across northern New South Wales is highly variable. Areas with low service availability should be targeted by policy.

      PubDate: Mon, 8 May 2017 19:11:53 GMT
       
  • Volume 46 Issue 5 - Patterns of complementary and alternative medicine use
           and health literacy in general practice patients in urban and regional
           Australia
    • Abstract: von Conrady, Dora M; Bonney, Andrew
      Background and objective: The majority of Australians use complementary and alternative medicine (CAM). Despite concerns about safety, patterns of health literacy and CAM use in Australian general practice are unknown.

      Methods: Pre-existing questionnaires assessing health literacy and CAM use (HLQ and I-CAM-Q) were distributed by eight practices across four Australian states to 800 patients aged 18 years and older for self-completion. Regression modelling and cluster analysis were applied to the data.

      Results: The response rate was 47% (n = 374), the mean age was 53 years and 68% of participants were female. Two-thirds of participants used some form of CAM in the previous 12 months, and 60% believed CAM aided wellbeing. There were significant associations between cluster membership, education, sex and CAM use.

      Discussion: Our findings suggest CAM use is a complex phenomenon, associated with gender and education. We demonstrated a cluster of female patients with high CAM use and lower health literacy warranting further research.

      PubDate: Mon, 8 May 2017 19:11:53 GMT
       
  • Volume 46 Issue 5 - Letters
    • PubDate: Mon, 8 May 2017 19:11:53 GMT
       
  • Volume 46 Issue 5 - Beyond anxiety and agitation: A clinical approach to
           akathisia
    • Abstract: Tachere, Richardson Oghoteru; Modirrousta, Mandana
      Background: When patients suddenly become restless and are unable to sit or stand still, especially in general medical settings, anxiety is often the topmost differential on every clinician's mind. However, the possibility of the very subjectively distressing condition called 'akathisia' should always be considered.

      Objective: The aim of this article is to discuss a clinical approach to the management of akathisia, drawing on the presentation of a patient who was admitted to a general medical ward.

      Discussion: Akathisia, a subjective and very distressing feeling of restlessness, has been found to be caused by a wide range of medications used in general medical settings, such as azithromycin, antiemetics and antipsychotics. Despite its high incidence and association with an increase in suicidal thoughts, it often goes unrecognised. This paper highlights the need for its early recognition, provides a diagnostic guide and an approach to its management.

      PubDate: Mon, 8 May 2017 19:11:53 GMT
       
  • Volume 46 Issue 5 - Ulipristal acetate: An update for Australian GPs
    • Abstract: Mazza, Danielle
      Background: In Australia, use and understanding of emergency contraception among women remains relatively low. This is despite the introduction of levonorgestrel emergency contraceptive pills (ECPs) more than a decade ago. In April 2016, a new ECP with the active ingredient ulipristal acetate became available in Australia.

      Objectives: The aims of this article are to increase understanding of the recently introduced ulipristal acetate ECP, including its safety profile, efficacy and special considerations; dispel common myths and misconceptions about emergency contraception; and to provide guidance on emergency contraceptive management in general practice, considering the recent advances.

      Discussion: Women are more receptive to information about emergency contraception that has been provided by a general practitioner (GP). As such, the availability of the ulipristal acetate ECP in Australia provides an important opportunity for GPs to help women prevent unplanned pregnancies.

      PubDate: Mon, 8 May 2017 19:11:53 GMT
       
  • Volume 46 Issue 5 - Improving blood pressure control in general practice:
           A pilot study of the ImPress intervention
    • Abstract: Zwar, Nicholas; Hermiz, Oshana; Halcomb, Elizabeth; Davidson, Patricia; Bodenheimer, Thomas
      Background and objectives: Patients with hypertension and at high absolute cardiovascular disease risk are a priority group for improved blood pressure control. This study examined the impact of an intervention, primarily delivered by the general practice nurse, to identify, recall and manage patients with uncontrolled hypertension who are at high risk of cardiovascular disease.

      Methods: A before-and-after pilot study with a six-month follow-up period was conducted in eight general practices in Sydney, Australia.

      Results: From 507 patients identified, 82 (16.2%) attended an assessment visit, were eligible and provided baseline data. Of these, 55 (67.1%) completed the six-month follow-up. The mean decrease in blood pressure was 14.5 mmHg systolic and 7 mmHg diastolic. Significant decreases were also found in mean weight (1.3 kg), body mass index (0.5 kg/m2) and waist circumference (1.9 cm). Adherence to blood pressure treatment, as measured by the Hill-Bone scale, significantly improved (P = 0.01)

      Discussion: The results of this study justify further investigation in a randomised trial. If effective, the approach could alter the way hypertension care is organised and delivered in Australian general practice.

      PubDate: Mon, 8 May 2017 19:11:53 GMT
       
  • Volume 46 Issue 5 - Skin biopsy in the diagnosis of neoplastic skin
           disease
    • Abstract: Harvey, Nathan Tobias; Chan, Jonathan; Wood, Benjamin Andrew
      Background: Biopsy for diagnostic and therapeutic purposes is a central component in the management of neoplastic skin conditions. While the technical aspects of performing biopsies are familiar to most clinicians, a number of other aspects of the skin biopsy pathway are equally important.

      Objectives: The objectives of this article are to provide general principles related to the biopsy of neoplastic skin conditions and offer practical advice on the approach to some common skin neoplasms.

      Discussion: Careful attention to the selection of biopsy site and type, and communication of appropriate clinical details will ensure optimal patient care, minimising the chance of diagnostic errors with potentially serious medical and medico-legal consequences.

      PubDate: Mon, 8 May 2017 19:11:53 GMT
       
  • Volume 46 Issue 5 - Cognitive errors in the management of skin conditions:
           Rash decisions and alternative facts
    • Abstract: Duns, Glenn
      PubDate: Mon, 8 May 2017 19:11:53 GMT
       
  • Volume 46 Issue 5 - Scabies: A clinical update
    • Abstract: Hardy, Myra; Engelman, Daniel; Steer, Andrew
      Background: Scabies is a common, yet neglected, skin disease. Scabies occurs across Australia, but most frequently in socioeconomically disadvantaged populations in tropical regions, including in remote Aboriginal and Torres Strait Islander communities. In temperate settings, the disease clusters in institutional care facilities.

      Objectives: The objective of this article is to provide updates on the clinical diagnosis and treatment approaches for scabies in Australia.

      Discussion: Clinical examination remains the mainstay of diagnosis, although dermatoscopy is a useful adjunct. Scabies presents with severe itch and a papular rash, with a predilection for the hands, feet and genitalia. The distribution may be more widespread in infants and older people. Secondary bacterial infection is also common in patients with scabies. Crusted scabies is a rare but highly infectious variant. Topical permethrin is highly effective for individual treatment, but less practical for treatment of asymptomatic contacts and control of outbreaks. Oral ivermectin is a safe and effective alternative, and is now listed on the Pharmaceutical Benefits Scheme as a third-line treatment.

      PubDate: Mon, 8 May 2017 19:11:53 GMT
       
  • Volume 46 Issue 5 - Optimising cryosurgery technique
    • Abstract: Cranwell, William C; Sinclair, Rodney
      Background: Cryosurgery is an effective, simple and inexpensive treatment used extensively in general practice and dermatology. It is used most commonly for actinic keratoses and warts; however, a large number of benign, premalignant and malignant skin diseases can also be treated.

      Objective: The objective of this article is to help readers improve their cryosurgery technique.

      Discussion: Application of the cryogenic agent (most commonly liquid nitrogen) to the skin induces rapid freezing followed by slow thawing. This produces cell injury, vascular stasis and occlusion, and inflammation. The quantity of cryogen delivered onto the skin (dose), technique, duration of thawing and amount of surrounding tissue frozen are dependent on the body region and type of lesion. If clinical diagnosis is not possible, either a skin biopsy or referral to a dermatologist is recommended. We strongly discourage blind treatment of undiagnosed skin lesions.

      PubDate: Mon, 8 May 2017 19:11:53 GMT
       
  • Volume 46 Issue 5 - Rosacea
    • Abstract: Maor, Danit; Chong, Alvin H
      Background: Rosacea is a chronic and common cutaneous condition characterised by symptoms of facial flushing and a broad spectrum of clinical signs. The clinical presentation for rosacea is varied, and there are four primary subtypes, which may overlap - erythrotelangiectatic, inflammatory, phymatous and ocular. It is important to recognise the different subtypes because of the differences in therapy.

      Objective: The objective of this article is to provide evidence-based clinical updates to clinicians, specifically general practitioners (GPs), to assist with their everyday practice, and effective assessment and treatment of rosacea.

      Discussion: Therapeutic modalities are chosen on the basis of the subtypes and clinical features identified; often a combination of these therapies is required.

      PubDate: Mon, 8 May 2017 19:11:53 GMT
       
  • Volume 46 Issue 5 - Skin biopsy in the diagnosis of inflammatory skin
           disease
    • Abstract: Harvey, Nathan Tobias; Chan, Jonathan; Wood, Benjamin Andrew
      Background: Most non-neoplastic skin conditions are readily diagnosed by a combination of clinical history and examination, but in a small number of cases, biopsy for histopathology and other laboratory investigations can be invaluable tools. Close attention to communication of appropriate clinical details, selection of biopsy site and biopsy technique have a marked impact on the diagnostic yield of this procedure.

      Objectives: The objectives of this article are to provide general principles related to the biopsy of non-neoplastic skin conditions and offer practical advice on the approach to some common skin conditions.

      Discussion: In this article, we discuss a number of general principles that will ensure maximum benefits can be achieved when a biopsy is performed for the diagnosis of non-neoplastic skin disease.

      PubDate: Mon, 8 May 2017 19:11:53 GMT
       
  • Volume 46 Issue 4 - Cancer and the omics revolution
    • Abstract: Epstein, Richard J; Lin, Frank P
      Background: Internal medicine is in flux because of the 'omics revolution', with cancer medicine being a good example. Molecular technologies that detect alterations in gene-based structure or function are having an impact on diagnosis, prognosis and treatment of cancer.

      Objective: In this article, recent advances in gene-based characterisation of cancer are presented, and illustrated where possible by clinical applications.

      Discussion: The research-based vision of precision medicine is now on its way to becoming a clinical reality. A key limiting factor is the small number of therapeutic options available for customisation, which contrasts with the rising abundance of omics-derived data. However, further translational progress is anticipated over the next decade.

      PubDate: Wed, 12 Apr 2017 22:31:47 GMT
       
  • Volume 46 Issue 4 - How can GPs drive software changes to improve
           healthcare for Aboriginal and Torres Strait Islander peoples?
    • Abstract: Kehoe, Helen
      Background: Changes to the software used in general practice could improve the collection of the Aboriginal and Torres Strait Islander status of all patients, and boost access to healthcare measures specifically for Aboriginal and Torres Strait Islander peoples provided directly or indirectly by general practitioners (GPs).

      Objective: Despite longstanding calls for improvements to general practice software to better support Aboriginal and Torres Strait Islander health, little change has been made. The aim of this article is to promote software improvements by identifying desirable software attributes and encouraging GPs to promote their adoption.

      Discussion: Establishing strong links between collecting Aboriginal and Torres Strait Islander status, clinical decision supports, and uptake of GP-mediated health measures specifically for Aboriginal and Torres Strait Islander peoples - and embedding these links in GP software - is a long overdue reform. In the absence of government initiatives in this area, GPs are best placed to advocate for software changes, using the model described here as a starting point for action.

      PubDate: Wed, 12 Apr 2017 22:31:47 GMT
       
  • Volume 46 Issue 4 - A survey of hepatitis C management by Victorian GPs
           after PBS-listing of direct-acting antiviral therapy
    • Abstract: Wade, Amanda; Draper, Bridget; Doyle, Joseph; Allard, Nicole; Grinzi, Paul; Thompson, Alexander; Hellard, Margaret
      Background and objective: To increase access to hepatitis C virus (HCV) treatment, the Pharmaceutical Benefits Scheme (PBS) enabled general practitioners (GPs) to prescribe directacting antiviral (DAA) therapy. We conducted a survey to identify GPs' knowledge and management of HCV.

      Methods: A questionnaire consisting of 20 items about HCV knowledge and management was sent to 1000 GPs.

      Results: One hundred and ninety-one GPs (19.1%) responded; 74% answered correctly that antibody and RNA positivity is diagnostic of HCV. Only 12% could directly request transient elastography. Although 53% of respondents reported interest in prescribing DAAs, 72% continued to refer all patients to specialists. Fifty-five per cent were unsure if people who currently inject drugs were eligible for treatment.

      Discussion: Most respondents were interested in prescribing DAAs, but education, access to transient elastography and clear consultation pathways are required to translate this interest into increased treatment availability. PBS eligibility of current injectors needs promotion.

      PubDate: Wed, 12 Apr 2017 22:31:47 GMT
       
  • Volume 46 Issue 4 - A sugary problem
    • Abstract: Foster, Emma; Gao, Phoebe; Zavala, Jorge
      Sarah, 20 years of age, is a student who presented to her family doctor with a one-day history of vertigo and occipital headache. She denied photophobia, neck stiffness, or altered vision or hearing. Sarah had been admitted to a general hospital ward one week earlier with a diagnosis of viral gastroenteritis complicated by diabetic ketoacidosis (DKA). At her presentation one week earlier, her initial pH was 7.28, bicarbonate was 13 mmol/L and ketones were 4.4 mmol/L. She had an uncomplicated recovery with standard care, including fluid rehydration and an insulin infusion. Sarah's medical history included type 1 diabetes mellitus, diagnosed at 8 years of age, with no previous DKA episodes or vascular complications. A recent glycated haemoglobin (HbA1c) measurement was 62 mmol/mol (7.8%). She selfadministered insulin detemir twice daily and insulin aspart with meals. Sarah was not on any other regular medication, and there was no other significant personal or family medical history. She denied smoking cigarettes, use of alcohol or recreational drugs, including no cocaine or amphetamine use.

      PubDate: Wed, 12 Apr 2017 22:31:47 GMT
       
  • Volume 46 Issue 4 - Paradigm shifts
    • PubDate: Wed, 12 Apr 2017 22:31:47 GMT
       
  • Volume 46 Issue 4 - Conservation surgery and radiation therapy in early
           breast cancer - an update
    • Abstract: Tailby, Ellen; Boyages, John
      Background: Multiple randomised trials and meta-analyses have supported the use of conservative surgery (CS) and radiation therapy (RT) for the treatment of early-stage breast cancer. Following lumpectomy, RT has been shown to decrease the chance of local recurrence and improve overall survival when compared with lumpectomy alone.

      Objectives: This update outlines the rationale and outcomes for CS and RT, whether a subgroup exists in which RT may be safely omitted, the process of RT, common side effects and their management, and the latest techniques in the field.

      Discussion: Breast conservation remains an effective treatment for breast cancer without a survival disadvantage to a mastectomy. The combination of advanced imaging and fast three-dimensional (3D) radiotherapy planning computer systems have allowed new techniques that deliver RT more accurately, with better tumour control, fewer side effects and improved survival.

      PubDate: Wed, 12 Apr 2017 22:31:47 GMT
       
  • Volume 46 Issue 4 - Letters
    • PubDate: Wed, 12 Apr 2017 22:31:47 GMT
       
  • Volume 46 Issue 4 - The gut microbiome
    • Abstract: Sidhu, Mayenaaz; van der Poorten, David
      Background: More than a trillion, mostly good, microbes live within our gastrointestinal tract and are responsible for vital metabolic, immune and nutritional functions. Dysbiosis, meaning a maladaptive imbalance of the microbiome, is associated with many common diseases and is a target for therapy.

      Objectives: This article provides an overview of the gut microbiome in health and disease, highlighting conditions such as 'Clostridium difficile' infection, inflammatory bowel disease, irritable bowel syndrome, obesity and non-alcoholic fatty liver disease, with which dysbiosis is associated. Information about treatments that affect the gut microbiome, including probiotics and faecal microbiota transplant, are discussed.

      Discussion: As our knowledge of the microbiome increases, we are likely to better understand the complex interactions that cause disease, and develop new and more effective treatments for many common conditions.

      PubDate: Wed, 12 Apr 2017 22:31:47 GMT
       
  • Volume 46 Issue 4 - Advances in genomic testing
    • Abstract: Downie, Lilian; Donoghue, Sarah; Stutterd, Chloe
      Background: Advances in genomic technology and our understanding of Mendelian disease-causing genes have led to an increased use of genomic testing in clinical practice.

      Objective: The aim of this paper is to outline recent advances in genetic and genomic testing and the implications for clinical practice.

      Discussion: Next-generation genomic sequencing is improving the diagnostic yield for patients with suspected genetic disease. A molecular diagnosis for a patient with genetic disease can provide information regarding a patient's prognosis, management and reproductive risk, and identify molecular targets for treatment. However, genomic testing frequently identifies variants of uncertain significance. This is illustrated by two case examples.

      PubDate: Wed, 12 Apr 2017 22:31:47 GMT
       
  • Volume 46 Issue 4 - Immunotherapy of cancer
    • Abstract: Trapani, Joseph A; Darcy, Phillip K
      Background: For 50 years, cancer physicians have relied on just three primary treatment modalities: surgery, radiation therapy and chemotherapy. Over that time, enormous progress has been made in understanding cancer biology, targeted anticancer drugs have emerged, and thousands of clinical trials have taught us how best to craft treatment combinations that improve clinical outcomes. Only five years ago, a fourth and radically different form of therapy finally emerged: immune‑based cancer therapies.

      Objective: This review briefly outlines the history and theoretical framework underpinning cancer immunotherapy, and recent progress on several immunotherapeutic approaches.

      Discussion: Immune-based cancer therapies are already revolutionising the management of several types of hitherto intractable cancer, while offering immense hope that the burden of personal suffering and community cost due to cancer will diminish appreciably over the coming decades. At least two immunotherapeutic approaches, checkpoint inhibition and cellular therapy with autologous ('self') chimeric antigen receptor T cells (CAR T cells), now show indisputable evidence of efficacy in several cancer types, and promise yet more rapid progress as they are refined and we learn to combine them with existing conventional therapies and each other.

      PubDate: Wed, 12 Apr 2017 22:31:47 GMT
       
  • Volume 46 Issue 4 - A painful papule on the ear
    • Abstract: Stewart, Thomas Jonathan
      A previously well Lebanese woman aged 28 years, who wears a headscarf, presented to her general practitioner with a three-month history of an abruptly appearing, painful papule on the antihelix of her left ear. She denied any preceding trauma and had no personal or family history of skin cancer. She had type 3 skin on the Fitzpatrick scale. The lesion was a 4 mm papule with a central keratin plug (Figure 1) that was 'exquisitely' tender on palpation. Examination of lymph nodes in the neck was normal.

      PubDate: Wed, 12 Apr 2017 22:31:47 GMT
       
  • Volume 46 Issue 4 - Mucocutaneous lesions and nail pigmentation in a
           patient with essential thrombocytosis
    • Abstract: Algarra, Alba Calleja; Miguel, Raquel Aragon; Romero, Fatima Tous; Jimenez, Lidia Maronas
      A Moroccan man, 45 years of age, was referred to the dermatology department because of the progressive occurrence of asymptomatic cutaneous lesions on his hands and feet during the past three years. He had received several topical treatments, including corticosteroids, antifungals and antibiotics, but with no response. Physical examination revealed the presence of purplish-red, infiltrated plaques, symmetrically located only on the dorsum of proximal and distal interphalangeal joints of both hands (Figure 1A). The patient also had a pronounced hyperkeratosis on his palms and soles (Figure 1B), oral hyperpigmentation (Figure 2A) and nail changes in the form of longitudinal melanonychia (Figure 2B). He had been diagnosed with essential thrombocytosis, and had initiated treatment with oral hydoxyurea one year before the onset of the skin manifestations.

      PubDate: Wed, 12 Apr 2017 22:31:47 GMT
       
  • Volume 46 Issue 4 - Esperance pica study
    • Abstract: Ardeshirian, Kuroush A; Howarth, Donald A
      Background and objectives: Pica, the eating of non-foods, occurs particularly in children and pregnant women. It has been observed in communities all over the world. Pica is associated with iron deficiency and, in some environments, lead poisoning. This is the first time a study has assessed the prevalence of pica in Australia.

      Methods: The study assessed the prevalence of pica in an Australian rural community, using a questionnaire given to parents of 223 children aged 2-10 years attending the five general practice surgeries in the shire.

      Results: The prevalence of non-ice pica in the study group was 9.4%, and 3.6% of this group ate soil.

      Discussion: The presence of pica should alert the treating clinician to consider iron deficiency and, in the case of polluted environments, lead exposure.

      PubDate: Wed, 12 Apr 2017 22:31:47 GMT
       
  • Volume 46 Issue 4 - A synopsis of current international guidelines and new
           modalities for the treatment of varicose veins
    • Abstract: Kemp, Nicholas
      Background: The UK National Institute for Health and Care Excellence released new guidelines in 2013 recommending that endovenous thermal ablation (laser or radiofrequency) and ultrasound-guided foam sclerotherapy should be offered before conventional surgery for treatment of varicose veins and saphenous vein reflux.

      Objective: The aim of this article is to provide a synopsis of current international guidelines and recent advances for the treatment of varicose veins.

      Discussion: Conventional surgery involving classical high ligation and stripping of the saphenous vein has been standard practice for nearly a century. Surgery requires general anaesthesia and hospitalisation, and there is a high rate of recurrent disease. In the past decade there has been an international trend where the minimally invasive techniques of endovenous thermal ablation and ultrasound-guided foam sclerotherapy, which do not require hospitalisation, are beginning to displace surgery. These changes in technique have been supported by recently published international guidelines.

      PubDate: Wed, 12 Apr 2017 22:31:47 GMT
       
  • Volume 46 Issue 3 - Managing corneal foreign bodies in office-based
           general practice
    • Abstract: Fraenke, Alison; Lee, Lawrence R; Lee, Graham A
      Background: Patients with a corneal foreign body may first present to their general practitioner (GP). Safe and efficacious management of these presentations avoids sight-threatening and eye-threatening complications. Removal of a simple, superficial foreign body without a slit lamp is within The Royal Australian College of General Practitioners' (RACGP's) curriculum and scope of practice. Knowing the relevant procedural skills and indications for referral is equally important.

      Objective: The objective of this article is to provide an evidence-based and expert-based guide to the management of corneal foreign bodies in the GP''s office.

      Discussion: History is key to identifying patient characteristics and mechanisms of ocular injury that are red flags for referral. Examination techniques and methods of superficial foreign body removal without a slit lamp are outlined, as well as the procedural threshold for referral to an ophthalmologist.

      PubDate: Fri, 10 Mar 2017 21:36:07 GMT
       
  • Volume 46 Issue 3 - Burns dressings
    • Abstract: Douglas, Helen E; Wood, Fiona
      Background: Burn injuries are common and costly; each year, there are more than 200,000 cases, costing the Australian community $150 million. Management of smaller burn injuries in the community can be improved by appropriate first aid, good burn dressings and wound management. This can reduce the risk of the burn becoming deeper or infected, and can potentially reduce the requirement for specialist review or surgery.

      Objectives: The objective of this article is to provide healthcare professionals with information about the pathophysiology of burn wound progression. This information includes the aims of burn wound dressings and indications for different types of dressings in different burn depths, advantages of blister debridement, and the reasoning behind advice given to patients after healing of the burn wound.

      Discussion: This article provides a framework used by the State Burn Service of Western Australia, by which clinicians can understand the needs of a specific burn wound and apply these principles when choosing an appropriate burn dressing for their patient. Every intervention in the journey of a patient with a burn injury affects their eventual outcome. By managing all burn injuries effectively at every single step, we can reduce burn injury morbidity as a community.

      PubDate: Fri, 10 Mar 2017 21:36:07 GMT
       
  • Volume 46 Issue 3 - The short Synacthen test and laboratory assay
           interference
    • Abstract: Choy, Kay Weng; Choy, Kay Hau
      Michael, 50 years of age, presented with increasing dizziness that was aggravated by standing, although there was no postural hypotension. His general practitioner (GP) requested testing for plasma thyroid-stimulating hormone (TSH) levels to exclude hypothyroidism, and plasma adrenocorticotrophic hormone (ACTH) and cortisol to exclude primary adrenal insufficiency. His medical history included hypertension and type 2 diabetes mellitus. Michael's test results are shown.

      PubDate: Fri, 10 Mar 2017 21:36:07 GMT
       
  • Volume 46 Issue 3 - A suspicious pigmented lesion in a transplant patient
    • Abstract: Bala, Harini Rajgopal; Chong, Alvin H
      A man of Indian descent, 46 years of age, underwent a renal transplant two years ago for lupus nephritis. Aside from systemic lupus erythematosus, the patient had no other medical comorbidities. Immunosuppressive therapy included azathioprine 50 mg twice daily, tacrolimus 1 mg twice daily and prednisolone 5 mg daily. A 2 mm pigmented macule on his right sole was detected during a routine skin check (Figure 1). The pigmented lesion had not been noted previously. On examination with the naked eye, the lesion was unusual as it was darkly pigmented. Dermoscopy revealed a parallel ridge pattern with diffuse varying pigment and no involvement of furrows.

      PubDate: Fri, 10 Mar 2017 21:36:07 GMT
       
  • Volume 46 Issue 3 - Procedural skills remain an intrinsic component of
           office-based general practice in the 21st century
    • Abstract: Margolis, Stephen A
      PubDate: Fri, 10 Mar 2017 21:36:07 GMT
       
  • Volume 46 Issue 3 - Implanon NXT: Expert tips for best-practice insertion
           and removal
    • Abstract: Pearson, Suzanne; Stewart, Mary; Bateson, Deborah
      Background: The single rod etonogestrel contraceptive implant is available in Australia as Implanon NXT. It is a highly effective, long-acting reversible contraceptive method, which is suitable for most women across the reproductive lifespan.

      Objective: This article provides practical advice for clinicians who already insert and remove the contraceptive implant, as well as advice for those who have not yet acquired this procedural skill.

      Discussion: Contraceptive implant procedures are usually performed in the general practice setting. Clinicians can support women in making an informed choice to have an implant by providing information about their benefits, side effects and risks, and timely access to insertion. Training in the procedures and compliance with procedural instructions are essential to minimise risks, including deep insertion and damage to neurovascular structures.

      PubDate: Fri, 10 Mar 2017 21:36:07 GMT
       
  • Volume 46 Issue 3 - Performing therapeutic venesection in a doctor's
           surgery
    • Abstract: Lim, Hui Yin; Ho, Wai Khoon
      Background: Although venesection was widely applied in the past for the treatment of various ailments and diseases, in modern medical practice, it is indicated in very few conditions, namely, hereditary haemochromatosis, polycythaemia and porphyria cutanea tarda.

      Objective: This article briefly reviews the pathophysiology of these conditions, and the rationale and goals of therapeutic venesection as a treatment modality. It also summarises the venesection procedure itself and the considerations for setting up a venesection service in a doctor's surgery.

      Discussion: Venesection is generally safe and carries few side effects. Before commencing therapeutic venesection, management goals in terms of laboratory parameters should be set for individual patients. These patients should be monitored regularly so that set targets are met and not overshot as to render them anaemic and acutely symptomatic. Venesections should also be performed by persons familiar with the procedure and management of the attendant complications.

      PubDate: Fri, 10 Mar 2017 21:36:07 GMT
       
  • Volume 46 Issue 3 - Projectile fly larvae: A potentially underreported
           cause of ocular foreign body sensation and inflammation in Australia
    • Abstract: Kelman, Julian C; McPherson, Zachary E; Sim, Benjamin WC
      A previously well girl, 13 years of age, presented to the emergency department at a rural hospital complaining of a 'crawling' foreign body sensation in her right eye. Several hours earlier, she had been by the Murrumbidgee River when she felt something go into her eye.

      PubDate: Fri, 10 Mar 2017 21:36:07 GMT
       
  • Volume 46 Issue 3 - A case of double vision
    • Abstract: Mohamed-Yassin, Mohamed-Syarif; Baharudin, Noorhida; Mustafa, Norasyikin
      A woman, 62 years of age, presented to a general practice with a three-day history of persistent double vision. She described this as 'seeing two images side by side'. There was no previous history of diplopia or trauma, headache, vomiting, limb weakness or jaw claudication. She could not remember the last time she saw a medical practitioner. She was not on any regular medications. There was no family history of diabetes, hypertension or ischaemic heart disease.

      PubDate: Fri, 10 Mar 2017 21:36:07 GMT
       
  • Volume 46 Issue 3 - An unusual cause of pleuritic pain
    • Abstract: Mann, Joshua E
      A woman, 62 years of age, presented to the emergency department (ED) with rightsided pleuritic chest pain and dyspnoea following a long road trip from Adelaide to Northern Queensland. In the morning of the presentation, she had a coughing fit and became acutely short of breath. On arrival at the ED, she was anxious but had normal observations (heart rate: 80 beats per minute, blood pressure: 114/65 mmHg, oxygen saturation: 96% on room air, Glasgow Coma Scale: 15, afebrile). She had no significant past medical history, was a non-smoker, had no regular medications and had a body mass index (BMI) of 22 kg/m2.

      PubDate: Fri, 10 Mar 2017 21:36:07 GMT
       
  • Volume 46 Issue 3 - Lisfranc injuries
    • Abstract: Wynter, Sacha; Grigg, Cameron
      Background: Injury to the tarsometatarsal joint is a relatively rare occurrence that is commonly missed, leading to debilitating outcomes. For this reason, it is considered a red flag in general practice.

      Objective: This article reviews the current literature on tarsometatarsal injuries and describes clinical assessment, imaging and management.

      Discussion: Lisfranc injuries refer to the displacement of the metatarsals from the tarsus, with special attention placed on the second tarsometatarsal joint and Lisfranc ligament. These injuries can occur in numerous circumstances, such as motor vehicle accidents, crush injuries and falls. Indirect mechanisms include axial force through the foot or twisting on a plantar flexed foot. Suggestive examination signs include plantar ecchymosis, mid-foot pain and positive findings in the provocative tests described in the article. Weight-bearing radiographs are vital for diagnosis. Correct and prompt management is key to avoiding posttraumatic arthritis, a devastating but common complication of Lisfranc injuries.

      PubDate: Fri, 10 Mar 2017 21:36:07 GMT
       
  • Volume 46 Issue 3 - Comparison of efficacy and tolerability of
           pharmacological treatment for the overactive bladder in women: A network
           meta-analysis
    • Abstract: Nalliah, Sivalingam; Gan, Pou Wee; Masten Singh, Premjit K; Naidu, Piravin; Lim, Vivian; Ahamed, Arshad ASA
      Background and objective: Overactive bladder syndrome (OAB) is a common medical condition that causes significant distress and impact on the quality of life in women. Muscarinic receptor antagonists remain the mainstay of therapy, but they are limited by their efficacy and adverse effects. The objective of the article was to compare the clinical efficacy and tolerability of medications used to treat OAB in women through network meta-analysis.

      Methods: Data from eligible studies of commonly prescribed pharmacological agents in the treatment of OAB in women were entered into NetMetaXL after a literature search using two online databases (PubMed and Cochrane). Studies between 31 July 2000 and 31 July 2015 were included in this study.

      Results: Five quantitative studies were eligible for analysis. The most efficacious drug to treat OAB in women appears to be solifenacin 10 mg once daily (OD), followed by oxybutynin 3 mg three times a day. However, solifenacin 10 mg OD caused more adverse effects that the other treatments.

      Discussion: Our results are similar to those of another systematic review. When considering efficacy, tolerability and cost, solifenacin 5 mg once daily is the drug of choice as it is more efficacious, albeit with more adverse effects, than other treatments. If solifenacin is unsuitable, oxybutynin 3 mg TDS is recommended.

      PubDate: Fri, 10 Mar 2017 21:36:07 GMT
       
  • Volume 46 Issue 3 - Older people and knowledge of epilepsy: GPs can help
    • Abstract: Peterson, Chris L; Piccenna, Loretta; Williams, Sue; Batchelor, Frances; Dow, Briony; Shears, Graeme
      Background and objective: Epilepsy is a common neurological disease with a high prevalence in people aged 65 years or older. Therefore, an understanding of the disease is important. The objective of this article was to determine older people's knowledge of epilepsy.

      Methods: Electronic or paper-based surveys were completed by people aged 65 years and older.

      Results: Five hundred and seventy-two surveys were completed, including 100 from people with epilepsy. Those with epilepsy had relatively poor knowledge of their condition, but they answered some questions significantly more correctly than participants without epilepsy. The main predictor of knowledge was clear information from a health professional. Two-thirds of those with epilepsy had their condition managed by a general practitioner.

      Discussion: Older people with epilepsy need more information on their condition to facilitate better care management.

      PubDate: Fri, 10 Mar 2017 21:36:07 GMT
       
  • Volume 46 Issue 3 - Research in general practice
    • Abstract: Gunn, Jane; Pirotta, Marie
      This article is the first in a series on general practice research in Australia. The series explores strategies to strengthen general practice research and further develop the evidence base for primary care.

      PubDate: Fri, 10 Mar 2017 21:36:07 GMT
       
  • Volume 46 Issue 3 - Teaching rational prescribing to general practice
           registrars: A guide for supervisors
    • Abstract: Morgan, Simon
      Background: Pharmaceuticals play an important role in modern day healthcare, and prescribing is a very common activity in Australian general practice. However, there are significant harms associated with medicine use. Vocational training is a critical period in the development of clinical practice patterns for the future general practitioner (GP), including prescribing behaviour. The general practice supervisor, therefore, has a key role to play in educating registrars about rational prescribing.

      Objective: In this article, we discuss a range of practical strategies for general practice supervisors to use when teaching their registrars rational prescribing in the practice setting.

      Discussion: Teaching rational prescribing should take on a patient-centred focus and incorporate an approach to managing uncertainty. Role-modelling of quality prescribing and use of guidelines is a strong influence on registrar behaviour. Specific strategies include random case analysis, audit and feedback of prescribing practice, topic tutorials and use of specific prescribing resources.

      PubDate: Fri, 10 Mar 2017 21:36:07 GMT
       
  • Volume 46 Issue 3 - Undescended testes: Diagnosis and timely treatment in
           Australia (1995-2014)
    • Abstract: Vikraman, Jaya; Donath, Susan; Hutson, John M
      Background and objective: Routine primary care checks in infants and prepubertal boys aim for early detection and intervention of undescended testes (UDT). Congenital and acquired UDT cause infertility, and congenital UDT also increases testicular cancer risk. We examined 20 years of Australian orchidopexy data (1995-2014) to explore the national orchidopexy operation rates over time.

      Methods: Orchidopexy and population data were collected from the Australian Bureau of Statistics (ABS) for 1995-2014, and census data for each age group were also collected. Poisson regressions were used to analyse the data.

      Results: For patients aged < 5 years, there was no change in orchidopexy rates over time. For those aged 5-14 years, there was a decline of 2.9% per year in treatment of likely acquired UDT, and there was a small increase for those aged 15-24 years.

      Discussion: The rate of orchidopexy per age has decreased in patients aged 5-14 years over the past 20 years, possibly indicating that acquired UDT is not being diagnosed and treated in some boys, risking infertility in adulthood.

      PubDate: Fri, 10 Mar 2017 21:36:07 GMT
       
  • Volume 46 Issue 3 - Parental attitudes, beliefs, behaviours and concerns
           towards childhood vaccinations in Australia: A national online survey
    • Abstract: Chow, Maria Yui Kwan; Danchin, Margie; Willaby, Harold W; Pemberton, Sonya; Leask, Julie
      Background and objectives: Vaccine hesitancy is a public health concern. The objectives of this article were to describe Australian parents' attitudes, behaviours and concerns about vaccination, determine the factors associated with vaccination non-compliance, and provide sources of vaccination information for general practitioners (GPs).

      Methods: We conducted a nationally representative online survey of Australian parents in 2012. We determined associations between demographic and vaccination attitudes and behaviour.

      Results: The 452 respondents were parents of children aged
      PubDate: Fri, 10 Mar 2017 21:36:07 GMT
       
  • Volume 46 Issue 3 - Clinical challenge
    • PubDate: Fri, 10 Mar 2017 21:36:07 GMT
       
  • Volume 46 Issue 3 - Family medicine: The classic papers [Book Review]
    • Abstract: McCoy, Ronald
      Review(s) of: Family medicine: The classic papers, Edited by Michael Kidd, Iona Heath, Amanda Howe, CRC Press, Taylor & Francis Group New York, 2017, ISBN: 9781846199943.

      PubDate: Fri, 10 Mar 2017 21:36:07 GMT
       
  • Volume 46 Issue 3 - Echocardiography and clozapine: Is current clinical
           practice inhibiting use of a potentially life-transforming therapy'
    • Abstract: Robinson, Gail; Kisely, Steve; Siskind, Dan; Flanagan, Robert J; Wheeler, Amanda J
      Approximately 33% of patients with schizophrenia are treatmentrefractory, yet clozapine remains underused, even though it is the most effective treatment. One barrier is routine echocardiography, which in Australia is performed before clozapine initiation, six months afterwards and then annually. Elsewhere, such as in New Zealand, routine echocardiography is generally restricted to the initiation of therapy, while in the UK, it is not routine practice at all. Importantly, the latest guidelines from The Royal Australian and New Zealand College of Psychiatrists (RANZCP) suggest routine annual echocardiography adds little to the detection of cardiomyopathy. We therefore review the evidence for routine echocardiography. This is particularly relevant to general practitioners (GPs) as they become more involved in managing patients on clozapine through shared-care arrangements.

      PubDate: Fri, 10 Mar 2017 21:36:07 GMT
       
  • Volume 46 Issue 1/2 - Clinical challenge
    • PubDate: Mon, 6 Feb 2017 17:36:50 GMT
       
  • Volume 46 Issue 1/2 - Letters
    • PubDate: Mon, 6 Feb 2017 17:36:50 GMT
       
  • Volume 46 Issue 1/2 - The joy of life
    • Abstract: Margolis, Stephen A
      PubDate: Mon, 6 Feb 2017 17:36:50 GMT
       
  • Volume 46 Issue 1/2 - Healthy ageing
    • Abstract: Sims, Jane
      Background: The increasing number of people reaching their 80s and 90s has triggered multidisciplinary consideration of how to address and capitalise on the longevity phenomenon.

      Objective: The aim of this article is to provide an overview of ways in which clinicians can work with older patients to optimise their health and wellbeing during the later years of life.

      Discussion: Old age need not be burdensome to individuals or society. There is strong evidence to support the management of many chronic diseases presenting in - or extending into - old age. General practice will need to adapt to the demographic challenges of an ageing population by targeting conditions that impede people from contributing to family and societal life. General practitioners (GPs) will also need to adapt to the changing expectations of, and from, older patients across the upcoming generations.

      PubDate: Mon, 6 Feb 2017 17:36:50 GMT
       
  • Volume 46 Issue 1/2 - Enjoying a healthy pregnancy: GPs' essential role in
           health promotion
    • Abstract: Frayne, Jacqueline; Hauck, Yvonne
      Background: For many women, a major pregnancy goal is to achieve an enjoyable, healthy pregnancy. The continuum of care from preconception counselling, management of early pregnancy, referral or continued pregnancy care and management into the postpartum period places general practitioners (GPs) in a unique position to meaningfully contribute on many levels to this realisation.

      Objectives: The aim of this article is to explore the determinants of a healthy and enjoyable pregnancy, and asks how GPs can facilitate an optimum experience for women in pregnancy, regardless of risk.

      Discussion: GPs can play a key role with prospective parents in health promotion, directing them to appropriate resources and services; addressing disease prevention by targeting modifiable lifestyle risks; and managing chronic health concerns in the optimisation of pregnancy care.

      PubDate: Mon, 6 Feb 2017 17:36:50 GMT
       
  • Volume 46 Issue 1/2 - Let's talk about sex
    • Abstract: Goodwach, Raie
      Background: As sexual wellbeing is an important aspect of good general health, and sexual difficulties are a concern for 20-40% of the adult population, general practitioners (GPs) have a key role to play in initiating discussions about sex and sexual difficulties with their patients.

      Objective: This article encourages GPs to take the lead in initiating a conversation about sex and sexual difficulties with their patients by taking a brief sexual history as a routine part of a medical history. If any sexual concerns are identified, a longer appointment can be arranged for a detailed history and examination, and to discuss treatment options, including referral.

      Discussion: Sexual difficulties are common and can affect a patient's quality of life. There is a high risk of sexual difficulties arising from illness, medication, and personal and relationship difficulties. Erectile dysfunction is particularly important to identify as it is a predictor of cardiovascular and other microvascular disease.

      PubDate: Mon, 6 Feb 2017 17:36:50 GMT
       
  • Volume 46 Issue 1/2 - Healthy living
    • Abstract: Egger, Garry
      Background: The nature of disease changes with the nature of societies. Modern chronic diseases that have superseded infections in the Anthropocene era, for example, have come largely from modern environments and lifestyles emanating from this. The concept of healthy living has subsequently changed accordingly.

      Objective: The objective of this article is to examine the determinants of modern chronic disease and the changes that can be made at the individual level to reduce the impact of these.

      Discussion: There is a hierarchy of determinants (sometimes incorrectly called 'causes') of the major modern chronic diseases. These are summarised under the acronym NASTIE MAL ODOURS and collectively under the term 'anthropogens', which are '... man-made environments and the lifestyles associated with these, many of which may lead to disease'. Attention to anthropogens in a systems fashion suggest guidelines for modern healthy living.

      PubDate: Mon, 6 Feb 2017 17:36:50 GMT
       
  • Volume 46 Issue 1/2 - Trans-oral robotic surgery in oropharyngeal
           carcinoma - a guide for general practitioners and patients
    • Abstract: Liu, Wendy Sijia; Limmer, Alex; Jabbour, Joe; Clark, Jonathan
      Background: Trans-oral robotic surgery (TORS) is emerging as a minimally invasive alternative to open surgery, or trans-oral laser surgery, for the treatment of some head and neck pathologies, particularly oropharyngeal carcinoma, which is rapidly increasing in incidence.

      Objective: In this article we review current evidence regarding the use of TORS in head and neck surgery in a manner relevant to general practice. This information may be used to facilitate discussion with patients.

      Discussion: Compared with open surgery or transoral laser surgery, TORS has numerous advantages, including no scarring, less blood loss, fewer complications, lower rates of admission to the intensive care unit, and reduced length of hospitalisation. The availability of TORS in Australia is currently limited and, therefore, public awareness about TORS is lacking. Details regarding the role of TORS and reliable, up-to-date, patient-friendly information sources are discussed in this article.

      PubDate: Mon, 6 Feb 2017 17:36:50 GMT
       
  • Volume 46 Issue 1/2 - Persistent suppression of viral load in chronic
           hepatitis B
    • Abstract: Mascarenhas, Lester; Sutton, Leonie
      Ruby, 41 years of age, is from the Karen state of Myanmar. She migrated to Australia as a humanitarian entrant in 2008. Shortly after her arrival, she underwent refugee health screening and was diagnosed with chronic hepatitis B. Since that time, Ruby has been under primary care surveillance. She is not on treatment for hepatitis B and has a suppressed viral load. Abdominal ultrasonography and liver elastography at diagnosis showed no liver fibrosis. Ruby does not drink alcohol. She has no other chronic diseases and does not take any regular medication. Her serology at diagnosis is shown in Box 1 and her latest results are shown in Boxes 2 and 3.

      PubDate: Mon, 6 Feb 2017 17:36:50 GMT
       
  • Volume 46 Issue 1/2 - Laryngopharyngeal reflux: A confounding cause of
           aerodigestive dysfunction
    • Abstract: Fraser-Kirk, Kristy
      Background: Laryngopharyngeal reflux (LPR) is one of the most common and important disorders of upper airway inflammation. It causes significant impairment to quality of life, and can predict serious laryngeal and oesophageal pathology, yet it remains under-diagnosed and undertreated.

      Objectives: This paper attempts to unravel the diagnostic dilemma of LPR and provide a practical, discriminating approach to managing this common condition.

      Discussion: Historical red flags mandating early referral for specialist review are identified, and pathophysiology, symptomatology and common signs are reviewed. In addition, a comprehensive treatment plan consisting of lifestyle modifications, counselling aids and empirical medical therapy is proposed. A strategy for tracking clinical improvement using Belfasky's validated symptom index is included to aid counselling, compliance and follow-up.

      PubDate: Mon, 6 Feb 2017 17:36:50 GMT
       
  • Volume 46 Issue 1/2 - Oxycodone/naloxone: An unusual adverse drug reaction
    • Abstract: Lau, Fiona; Gardiner, Matthew
      A woman, 52 years of age, presented with a complex medical history, including chronic liver disease, transjugular intrahepatic portosystemic shunting, stage 1 oesophageal varices and depression. The relevant medications were slow-release and immediate-release oxycodone, and a selective serotonin reuptake inhibitor (SSRI), which she had been taking for more than one month.

      PubDate: Mon, 6 Feb 2017 17:36:50 GMT
       
  • Volume 46 Issue 1/2 - Palliative care in general practice: GP integration
           in caring for patients with advanced cancer
    • Abstract: Le, Brian; Eastman, Peter; Vij, Sita; McCormack, Fiona; Duong, Cuong; Philip, Jennifer
      Background and objective: Patients with advanced cancer often desire home-based care, placing general practitioners (GPs) at the centre of complex clinical situations. The objective of this article was to determine GPs' needs when providing home-based palliative care in collaboration with existing palliative care services.

      Method: A survey of GPs was conducted to determine knowledge, skills and confidence in providing community-based palliative care.

      Results: Of the 56 respondents, 82% reported that they were involved in palliative management of at least one cancer patient in the previous year. A significant number of GPs (31%) lacked confidence in providing this care because of patient complexity, inadequate training and insufficient resources. Other barriers included poor communication from specialists and treating teams. Factors facilitating provision of home-based palliative care were community palliative care services and links to hospital-based palliative care teams. Discussion This survey highlights the importance of support and resources to empower GPs to confidently provide home-based palliative care for patients with advanced cancer.

      PubDate: Mon, 6 Feb 2017 17:36:50 GMT
       
  • Volume 46 Issue 1/2 - Multiple hyperpigmented patches on a dark-skinned
           patient
    • Abstract: Moyano, Elisabeth Gomez; Pilar, Leandro Martinez; Garcia, Silvestre Martinez; Simonsen, Sara
      A Nigerian man aged 30 years presented with multiple itchy and hyperpigmented patches affecting the complete body surface. He had emigrated from Nigeria one month ago, and the lesions had appeared two months earlier. There were no associated symptoms such as fever, malaise, headache or arthralgia. Physical examination revealed oval and lichenoid patches with a well‑demarcated border, as well as black dots on his abdomen (Figure 1). The lesions had an asymmetric distribution.

      PubDate: Mon, 6 Feb 2017 17:36:50 GMT
       
  • Volume 46 Issue 1/2 - A pruritic vesicular rash
    • Abstract: Baptista, Ana; Madanelo, Sofia; Morais, Paulo
      A man, 30 years of age, presented with an intensely pruritic eruption that had been evolving for approximately two months. The rash was characterised by clusters of translucent, tense vesicles located symmetrically on the extensor surfaces of the arms and legs (Figure 1A, B), and by erythematous papules and small plaques on the buttocks (Figure 1C). Some of the lesions were excoriated with bloodstained crusting. The patient reported a loss of approximately 5 kg in weight, and several episodes of diarrhoea and abdominal discomfort in the previous year. The patient was otherwise healthy and denied any history of fever, photosensitivity or symptoms in other family members. Four punch biopsies of lesional and perilesional skin from the arms and buttocks were taken for routine histopathology and direct immunofluorescence (DIF).

      PubDate: Mon, 6 Feb 2017 17:36:50 GMT
       
  • Volume 46 Issue 1/2 - Young people have their say: What makes a
           youth-friendly general practice'
    • Abstract: Turner, Laura; Spencer, Leah; Chang, Julian; di Tommaso, Isabel; Tate, Magella; Allen, Penny; Cheek, Colleen; Cooper, Jane
      Background and objective: The health of young people can be considered an indicator of the health of Australia's future population. To improve access to healthcare, the perspectives of adolescents on the design and delivery of services need to be championed. The objective of this study was to identify what young people in north-west Tasmania value when seeking healthcare at general practices.

      Methods: The study was conducted at a single high school in rural Tasmania. Students aged 16-18 years were invited to participate in an electronic survey seeking their views and preferences for presenting to their general practitioner (GP).

      Results: One hundred and fifty-five students, with a mean age of 17 years, were surveyed. GPs were the usual healthcare providers for 98.4% of participants, and 86% stated that they would like to discuss mental health, substance use and sexual health with their GP.

      Discussion: GPs can improve access to care for young people through good communications skills and treating young people as young adults.

      PubDate: Mon, 6 Feb 2017 17:36:50 GMT
       
  • Volume 46 Issue 1/2 - Audit and feedback by medical students to improve
           the preventive care practices of general practice supervisors
    • Abstract: Gilkes, Lucy A; Liira, Helena; Emery, Jon D
      Background and objectives: Medical students benefit from their contact with clinicians and patients in the clinical setting. However, little is known about whether patients and clinicians also benefit from medical students. We developed an audit and feedback intervention activity to be delivered by medical students to their general practice supervisors. We tested whether the repeated cycle of audit had an effect on the preventive care practices of general practitioners (GPs).

      Methods: The students performed an audit on topics of preventive medicine and gave feedback to their supervisors. Each supervisor in the study had more than one student performing the audit over the academic year.

      Results: After repetitive cycles of audit and feedback, the recording of social history items by GPs improved. For example, recording alcohol history increased from 24% to 36%.

      Discussion: This study shows that medical students can be effective auditors, and their repeated audits may improve their general practice supervisors' recording of some aspects of social history.

      PubDate: Mon, 6 Feb 2017 17:36:50 GMT
       
  • Volume 46 Issue 1/2 - An Australian discharge summary quality assessment
           tool: A pilot study
    • Abstract: Mahfouz, Carl; Bonney, Andrew; Mullan, Judy; Rich, Warren
      Background and objective: Patients' transition from hospital care to their general practitioner (GP) can put them at risk of unforeseen adverse events, which can be minimised by the GP receiving timely access to hospital discharge summaries. The objective of this article was to develop and pilot a discharge summary assessment tool, inclusive of components that Australian GPs identified as being most important for the safe transfer of care.

      Method: Development of the instrument was informed by a literature review pertaining to key components of effective discharge summaries. These components were included in a survey instrument, which was piloted by Australian GP participants.

      Results: From 118 responses, the five highest ranked components of a discharge summary included lists of medications on discharge, diagnoses on discharge, reasons for any changes in medications, and details of follow-up arrangements and treatment in hospital.

      Discussion: This paper describes the initial development and results of piloting an Australian discharge summary quality assessment tool.

      PubDate: Mon, 6 Feb 2017 17:36:50 GMT
       
  • Volume 46 Issue 1/2 - How to read a paper: The basics of evidence-based
           medicine, 5th edn [Book Review]
    • Abstract: Ypinazar, Valmae
      Review(s) of: How to read a paper: The basics of evidence-based medicine, 5th edn, by Trisha Greenhalgh, BMJ Books, 2014, ISBN 1118800966.

      PubDate: Mon, 6 Feb 2017 17:36:50 GMT
       
  • Volume 46 Issue 1/2 - Naevus or melanoma': An inadequate paradigm for
           a small number of clinically important lesions
    • Abstract: Wood, Benjamin A; Harvey, Nathan T
      The large majority of melanocytic proliferations undergoing excisional biopsy are easily classified as benign melanocytic naevi or malignant melanoma by routine histological examination. However, there is a small group of lesions that do not easily fit this dichotomous approach.1 This is unsurprising, as histological diagnosis involves the subjective identification and interpretation of multiple, and sometimes disparate architectural and cytological features, almost all of which individually show an imperfect relationship with the true biological nature of a neoplasm. Broadly, these problematic melanocytic lesions fall into two (sometimes overlapping) groups.

      PubDate: Mon, 6 Feb 2017 17:36:50 GMT
       
  • Volume 45 Issue 12 - Chronic alcohol abuse
    • Abstract: Harrison, Christopher; Charles, Janice; Miller, Graeme C; Britt, Helena
      Alcohol is one of the most widely used drugs in Australia. According to the 2013 National Drug Strategy Household Survey (NDSHS), about four out of five Australians aged >=14 years consumed alcohol in the previous year, and 6.5% did so on a daily basis. Those most likely to drink daily were in the >=70 year age group; this included both men (21%) and women (10%). The Bettering the Evaluation and Care of Health (BEACH) study has measured alcohol consumption by patients over several years, as recorded at general practice encounters, to estimate the proportion of patients who were 'hazardous drinkers'. Between 2006-07 and 2015-16, the prevalence of 'hazardous' drinking decreased from 27.0% to 22.7% in adult patients.

      PubDate: Mon, 23 Jan 2017 16:13:31 GMT
       
  • Volume 45 Issue 12 - Prescription drug abuse - a timely update
    • Abstract: Monheit, Benny; Pietrzak, Danusia; Hocking, Sandra
      Background: Prescription drug abuse is a rising problem in Australia and pharmaceutical drugs have been the most frequent contributors to overdose deaths in Victoria in recent years.

      Objectives: The objectives of this article are to examine the main prescription drugs contributing to overdose deaths and to consider how doctors may help in reducing this problem.

      Discussion: Data from the Coroners Court of Victoria list the main drugs that contributed to drug-related deaths in 2009-15. Analysis of the data reveals that pharmaceutical drugs contributed to 80% of overdose deaths; benzodiazepines and opioids were the main drug groups involved. Strategies for reducing and managing prescription drug abuse in primary care settings are outlined in this article, including references to published evidence-based clinical guidelines from The Royal Australian College of General Practitioners (RACGP). The safety profile of buprenorphine/naloxone over methadone is noted and raised as a consideration for clinicians when assessing a patient for opioid replacement therapy.

      PubDate: Mon, 23 Jan 2017 16:13:31 GMT
       
  • Volume 45 Issue 12 - Substance abuse
    • Abstract: McDonald, Rachel
      PubDate: Mon, 23 Jan 2017 16:13:31 GMT
       
  • Volume 45 Issue 12 - Cannabis use and its associated disorders: Clinical
           care
    • Abstract: Copeland, Jan
      Background: Globally, cannabis is the most widely used and variably regulated illicit drug. The rates of use appeared to be stable in Australia at the time of the 2013 National Drug Strategy Household Survey, but levels of cannabis use disorder are rising and treatment seeking is increasing internationally.

      Objective: This article describes the prevalence of cannabis use, associated disorders (eg harms with early and frequent use), and information on assessment and management. Links to a range of free online and telephone resources are provided.

      Discussion: Cannabis use is common and around one in 10 people who ever used cannabis will go on to develop a cannabis use disorder diagnosable according to the 'Diagnostic and statistical manual of mental disorders', fifth edition criteria. Substance use disorders comorbid with mental health conditions are common, and the two should be assessed and treated concurrently. A screening algorithm and review of the evidence for psychosocial interventions, including technological platforms such as web-based and telephone, is provided.

      PubDate: Mon, 23 Jan 2017 16:13:31 GMT
       
  • Volume 45 Issue 12 - The inherited chronic pain patient
    • Abstract: Grinzi, Paul
      Background: The 'inherited' patient, where a patient switches to a new doctor, is a common and potentially challenging scenario, especially where drugs of dependence are involved. There are few resources to guide general practitioners (GPs) with an approach that ensures compassion and rational clinical decision-making.

      Objectives: The aim of this article is to guide GPs in an approach to taking over the care of an inherited patient and focuses on considerations of rational prescribing.

      Discussion: In taking over the care of a new patient's pharmacotherapy, GPs need to proactively assess how rational and legal the 'inherited' medications are, and decide whether to continue, modify or cease. Our knowledge of the role and risks of drugs of dependence has evolved considerably over the past decade. GPs, therefore, need to carefully consider the ongoing role of these medications for new and existing patients.

      PubDate: Mon, 23 Jan 2017 16:13:31 GMT
       
  • Volume 45 Issue 12 - Clinical practice guidelines and principles of care
           for people with dementia in Australia
    • Abstract: Dyer, Suzanne M; Laver, Kate; Pond, Constance D; Cumming, Robert G; Whitehead, Craig; Crotty, Maria
      Background: Dementia is a national health priority in Australia. Most people with dementia are over the age of 65 years, have a number of comorbidities and experience a trajectory of functional decline. General practitioners (GPs) have an important role in the diagnosis and management of people with dementia. The Cognitive Decline Partnership Centre's Clinical practice guidelines and principles of care for people with dementia (Guidelines) was recently approved by the National Health and Medical Research Council (NHMRC).

      Objective: This article describes the recommendations within the Guidelines that are of greatest relevance to GPs, including those addressing diagnosis, living well, managing behavioural and psychological symptoms, supporting carers, and the palliative approach.

      Discussion: The Guidelines synthesise current evidence in dementia care and emphasise: timely diagnosis; encouraging the person with dementia to exercise, eat well and keep doing as much for themselves as possible; supporting and training carers to provide care; and reducing prescription of potentially harmful medications where possible.

      PubDate: Mon, 23 Jan 2017 16:13:31 GMT
       
  • Volume 45 Issue 12 - Resuscitation update for general practitioners
    • Abstract: Grantham, Hugh; Christiansen, Rowena
      Background: The latest changes to resuscitation guidelines in Australia were released in 2016. Few of the changes will have an impact on general practitioners (GPs) but there are some additional issues that they, as health professionals and leaders in the community, should be informed about.

      Objective: The objective of this article is to provide an update for GPs on the current resuscitation guidelines.

      Discussion: This article describes the latest changes in resuscitation recommendations in the fields of first aid, basic life support, advanced life support and paediatric resuscitation, with an emphasis on issues of particular relevance to GPs.

      PubDate: Mon, 23 Jan 2017 16:13:31 GMT
       
  • Volume 45 Issue 12 - Management of bipolar disorder over the perinatal
           period
    • Abstract: Boyce, Philip; Buist, Anne
      Background: Women with bipolar disorder have a high risk of relapse following childbirth. The risk of relapse can be reduced by mood stabilisers, but they are potentially harmful to the developing fetus.

      Objective: The objective of this article is to provide an up-to-date review of the strategies for managing women with bipolar disorder over the perinatal period.

      Discussion: Discussing the risks of taking mood stabilisers or having a medication-free pregnancy is essential for women with bipolar disorder. The latter, with careful monitoring, is suggested for women with less severe illness and good supports. Full or partial prophylaxis with a mood stabiliser is recommended for women at higher risk of relapse. Careful monitoring during pregnancy, psychosocial interventions and planning for the postnatal period will aid in preventing bipolar disorder relapse. The general practitioner is ideally placed to take a key management role in liaising with the obstetric and mental health teams, and planning for the postnatal period.

      PubDate: Mon, 23 Jan 2017 16:13:31 GMT
       
  • Volume 45 Issue 12 - Resistance exercise-induced rhabdomyolysis: Need for
           immediate intervention and proper counselling
    • Abstract: Khalil, Maysaa A; Saab, Basem R
      Background: Rhabdomyolysis results from damage to skeletal muscle. Improper resistance training may result in rhabdomyolysis, which can cause acute kidney injury, serious metabolic abnormalities, compartmental syndrome and even death. Proper counselling for athletes may prevent this condition.

      Objectives: We present two patients with unilateral swelling after resistance exercise. The workup revealed rhabdomyolysis. We highlight the importance of counselling to prevent rhabdomyolysis secondary to resistance exercise.

      Discussion: Trainers and primary care physicians need to be educated about the main features of rhabdomyolysis and urgently refer trainees suspected of having this condition. Treatment consists mainly of hydration and correction of metabolic abnormalities. Primary care physicians need to counsel patients on ways to prevent rhabdomyolysis. Trainers and primary care physicians should instruct novice trainees who are performing resistance exercise to start low and gradually increase the load. Training with loads of 60-70% of one repetition maximum for 8-12 repetitions and use of one to three sets per exercise is recommended.

      PubDate: Mon, 23 Jan 2017 16:13:31 GMT
       
  • Volume 45 Issue 12 - Tonsillotomy: An alternative surgical option to total
           tonsillectomy in children with obstructive sleep apnoea
    • Abstract: Smith, Sabin
      Background: Total tonsillectomy remains one of the most common ear, nose and throat (ENT) procedures performed in children. General practitioners (GPs) are commonly involved in the referral of children with obstructive sleep apnoea (OSA). Intracapsular tonsilltomy (partial tonsillectomy) is fast becoming a popular surgical option to total tonsillectomy in children with OSA.

      Objective: The objective of this article is to provide information about partial tonsillectomy and its potential benefits over total tonsillectomy in the treatment of children with OSA for referring GPs.

      Discussion: Current evidence suggests that partial tonsillectomy is a safe and effective treatment for children with OSA. Partial tonsillectomy has been shown to be associated with a lower incidence of postoperative haemorrhage, faster recovery time and higher parent satisfaction than total tonsillectomy. Furthermore, it has been found to have comparable results to total tonsillectomy in the improvement of OSA symptoms in children.

      PubDate: Mon, 23 Jan 2017 16:13:31 GMT
       
  • Volume 45 Issue 12 - Prevalence and management of diabetes in residential
           aged care facilities in north-east Victoria, Australia
    • Abstract: Haines, Helen M; Bannon-Murphy, Holly; Amos, Tim; Krones, Robert
      Background: Managing diabetes in residential aged care facilities (RACFs) presents challenges to general practitioners (GPs) as the incidence of the disease increases.

      Objective: The objective of this article is to describe the prevalence and management of diabetes in RACFs in north-east Victoria.

      Method: The method used for this study was a cross-sectional audit of medical files.

      Results: Ten RACFs were invited and agreed to participate, giving a sample of 593 residents. Diabetes prevalence was 18.2% (n = 108). Half of the residents with diabetes had received a glycated haemoglobin (HbA1c) test in the previous six months. Of these residents, half had an HbA1c result of < 7%, and 18% > 8%. The frequency of hypoglycaemic events was found to be 10%. Hyperglycaemic episodes (HbA1C > 10%) occurred in 69% of residents with diabetes; 21% had hyperglycaemic episodes when defined by levels greater than those set by the resident's GP. Diabetes-related unscheduled hospitalisations was found to be 6.5%, while diabetes-related general practice visits was 23%.

      Discussion: The prevalence of diabetes in the RACFs was higher than previously reported in rural Victoria. Practice variance from evidence-based guidelines may be contributing to unplanned hospitalisations and increased acute general practice visits.

      PubDate: Mon, 23 Jan 2017 16:13:31 GMT
       
  • Volume 45 Issue 12 - General practitioners' knowledge and management of
           dry mouth - a qualitative study
    • Abstract: Appleby, Natalie J; Temple-Smith, Meredith J; Stacey, Margaret A; Bailey, Denise L; Deveny, Elizabeth M; Pirotta, Marie
      Background: Dry mouth (xerostomia) is common and can have significant consequences for a patient's general and oral health. Multiple medications may compromise the flow and quality of saliva.

      Objectives: This study explored general practitioners' (GPs') perceptions, knowledge and management of dry mouth, and whether consideration of oral health influences prescribing patterns.

      Methods: Semi-structured interviews with 20 GPs in Melbourne, Victoria, were audiotaped, transcribed and analysed.

      Results: GPs who participated in the study were aware of dry mouth, but diagnosed it infrequently. They had limited knowledge about the oral health implications and management of dry mouth, with some offering potentially harmful advice. Some participants reported that dry mouth would influence their prescribing, but few referred patients to dentists for management.

      Discussion: Dry mouth is not on GPs' radar, and patients are rarely questioned about this during routine medical examinations. GPs in this study would welcome additional information to enhance patients' oral health and patient resources on dry mouth.

      PubDate: Mon, 23 Jan 2017 16:13:31 GMT
       
  • Volume 45 Issue 12 - A nurse-led model of chronic disease management in
           general practice: Patients' perspectives
    • Abstract: Young, Jacqui; Eley, Diann; Patterson, Elizabeth; Turner, Catherine
      Background: Evidence suggests that current models of chronic disease management within general practice are not effective in meeting the needs of the community.

      Objective: The objective of this article is to examine patients' perceptions of a nurse-led collaborative model of care trialled in three general practices in Australia.

      Method: This article reports on the second phase of a mixed-methods study in which semi-structured interviews with purposively selected patients were conducted to elicit information about their perceptions of nurse-led care.

      Results: Three themes emerged from the data - time, ambiance and dimensions of the nurse role.

      Discussion: The results suggest that general practice nurses had a positive impact on patients' ability to manage their chronic disease. This infers that there is scope for general practice nurses to expand their role in chronic disease management to assist patients to better self-manage their chronic diseases.

      PubDate: Mon, 23 Jan 2017 16:13:31 GMT
       
  • Volume 45 Issue 12 - Bettering the Evaluation and Care of Health (BEACH):
           A unique role in the evolution of Australian general practice
    • Abstract: Beilby, Justin
      Understanding what we do every day as general practitioners (GPs) through a detailed and measureable approach has been, and will continue to be, crucial to strengthening our profession. I have been working with general practice information and available data sources for over 20 years and have always appreciated the ongoing role of Bettering the Evaluation and Care of Health (BEACH) as one of my principal sources of validation. Preparing applications for many research grants, justifying policy changes, introducing curricula reforms, assembling general practice workforce planning and training applications, debating primary care coding and satisfying my interest in understanding our discipline better have all benefited richly from accessing the BEACH data.

      PubDate: Mon, 23 Jan 2017 16:13:31 GMT
       
 
 
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