Australian Family Physician July 2006 - Wounds
Vol 35, (7) 465 - 560
The theme for the July issue of AFP is wounds.
This month's articles include plastic surgery made easy, wound repair in
children, leg ulcers, chronic nonmalignant pain, HIV seroconversion
illness, and acne and acne scarring.
Generalism in the specialisms
Steve Trumble
The theme of this month's Australian Family Physician - the management of wounds in primary care - is a
good example of general practitioners striking a balance between their clinical competence and the exigencies of daily practice. There is a significant amount of skill in
deciding which of these to manage ourselves and which to refer to another practitioner. Those decisions are not
as simple as they might seem.
Letters to the editor
The opinions expressed by correspondents in this column are in no way endorsed by either the Editors or The Royal Australian College of General Practitioners.
Skin excisions in Australian general practice
Janice Charles, Stephanie Knox, Helena Britt
The BEACH program, a continuous national study of general practice activity in Australia, gives us an overview of encounters where a skin excision was recorded as a procedure. This provides a backdrop against which the articles in this issue of Australian Family Physician can be further considered.
Wound repair in children
Ronan O’Sullivan, Ed Oakley, Mike Starr
Minor injuries in children are extremely common. The combination of a developing physical ability, lack of recognition of dangerous situations and a willingness to robustly explore their environment means that children are more likely than adults to injure themselves.
Leg ulcers - Causes and management
Sandra Dean
The majority of chronic leg ulcers presenting in general practice are the result of venous hypertension (~80%), arterial insufficiency (~10%) or a combination of both.1,2 Uncommon causes include lymphoedema,
vasculitis, malignancy and pyoderma gangrenosum.1
Which dressing should I use? - It all depends on the ’TIMEING’
Keryln Carville
Wound management is more than the application of a dressing. It requires a comprehensive and informed approach to the assessment of the patient, their wound, and their healing environment. The challenge for the general practitioner is how best to keep abreast of the
increasing body of research that informs best practice,
and the technological advances that expedite optimal
healing outcomes. In 1993, there were estimated to be
over 2000 wound dressings on the market.1
Plastic surgery made easy - Simple techniques for closing skin defects and improving cosmetic results
Terry Wu
'Will the surgery leave a scar?' is one of the most frequently asked questions that surgeons face. While operating on deeper structures may present more of a challenge for surgeons, patients often judge the skills of a surgeon by the cosmetic appearance and scarring resulting from surgery. With appropriate expertise and technique, a well placed fine line scar should be a goal that all surgeons aim to deliver to their patients.
Diabetes and the skin - Onychomycosis
Warren Weightman
Case history - Oliver is aged 70 years, has had type 2 diabetes for 18 years, and has been treated with insulin for 4 years. He presents after two episodes of cellulitis of his right lower leg and forefoot, which have cleared on antibiotics. There are no residual skin changes on his leg and forefoot other than some postinflammatory pigmentation.
Erythema induratum - A hypersensitivity reaction to Mycobacterium tuberculosis
Liang Joo Leow, Sylvia Pintens, Peter C Pigott,
Margot J Whitfeld
Erythema induratum (also known as Bazin disease, tuberculosum, tuberculosis cutis indurativa and nodose tuberculid) is a rare condition that produces painful, firm, and sometimes ulcerated nodules on the lower legs. Distinctive and diagnostic histopathology comprises a septolobular panniculitis, necrosis, granulomatous inflammation and vasculitis.
Treatments for damaged skin
Luis Vitetta, Avni Sali
This is the fifth of a series of articles looking at the
available evidence for complementary medicine
relating to the theme topic in Australian Family
Physician. Any ointment or device when applied to
damaged skin whether it be burned or cut, has a
legion of tasks to perform: maintaining the integrity
of the skin affected, repelling infective agents, and
promotion of the healing process.
Acne and acne scarring - The case for active and early intervention
Greg Goodman
Acne as a disease is so common as to be considered a normal rite of passage, and costs the community a substantial
amount in resources. Yet acne is a devastating disease striking most adolescents at their most vulnerable time when their life long self esteem and sense of identity is being developed.
One lump or two? A case study of infiltrating BCC on the nose
Anthony Dixon
Case history
A woman aged 42 years, who works as a hairdresser, presents with two apparent actinic lesions on the right of her nose (Figure 1). Close clinical examination reveals the lesions are likely to be
infiltrating basal cell carcinomas (BCCs). The lesions are firm with similar nontender indurations surrounding each site. Infiltrating BCCs can extend beyond the poorly defined clinical borders.
Chronic nonmalignant pain - The rational use of opioid medication
Michael Tedeschi
Every general practitioner has patients with chronic nonmalignant pain issues. At some point the possibility of using prescribed opioids is raised. General practitioners need to make the decision to initiate opioids cautiously, as a significant number of patients will gain little long term relief from these drugs, and some will exhibit problems resulting from dependence to the prescribed drug.
Point of care testing for C-reactive protein - A new path for Australian GPs?
Hasse Melbye, Nigel Stocks
The use of 'point of care testing' is emerging as
an important aspect of general practice care.1 Assay for C-reactive protein (CRP) is used widely
in Scandinavian countries and in Switzerland. In Norway, a CRP test is now performed in one out of 8 consultations, and in a Swedish survey from 2002, the CRP test was carried out in 41% of all patients consulting a general practitioner with an
airway infection.2
Osteoporotic fractures and vitamin D deficiency
Phillip Wong, Mahesan Anpalahan
Vitamin D deficiency is common among elderly people and numerous studies have confirmed its high prevalence in both selected and unselected samples.1-4 However, there is little information on the prevalence of osteomalacia in elderly people.5 As osteomalacia is
essentially a histological diagnosis, assessment of its
true prevalence is difficult, and reported prevalence has varied depending on the diagnostic criteria adopted.5
HIV seroconversion illness - latest HIV assays
Matthew Shields
Human immunodeficiency virus (HIV) seroconversion illness occurs in up to 80% of patients who newly acquire the virus.
It is hoped that the new fourth generation HIV assay will have improved sensitivity for diagnosis. This article describes the case of a patient who presented with typical symptoms of HIV seroconversion illness but who had a negative initial test with the new assay. Current management of HIV seroconversion illness is also outlined.
Clinical challenge
Jenni Parsons
Questions for this month's clinical challenge are based on articles in this issue. The style and scope of questions is
in keeping with the MCQ of the College Fellowship exam. The quiz is endorsed by the RACGP Quality Assurance and
Continuing Professional Development Program and has been allocated 4 CPD points per issue.
Accessory nerve injury
Sara Bird
This article discusses a Supreme Court judgment involving an injury to the spinal accessory nerve which occurred
during the excision of a lymph node mass in the posterior triangle of the neck.1
Brain teaser: Bilateral longitudinal splitting of toenails
Keng Yin Loh
A woman, 50 years of age, presented with recurrent lesions of her toenails for more than 5 years. The lesions were asymptomatic. There is no known preceding trauma to the affected nails. She was investigated for fungal
infection but the results were negative.
Opportunities and challenges for GPs in the developing world
Malcolm Moore
Australia has a well developed system of general practice and can be proud of the quality of its generalists. In many developing countries however, the idea of a trained generalist is not well understood. The global situation creates many opportunities and challenges for Australian general practitioners.
Shared decision making and decision aids - a literature review
Jill Thistlethwaite, Rebecca Evans, Rod Nan Tie, Clare Heal
Shared decision making (SDM) is a process within a patient centred consultation that involves both the patient and
doctor discussing management options and agreeing on management decisions in partnership.
Attitudes, knowledge and practice of CRC screening among GPs in Queensland
Philippa H Youl, Claire Jackson, Brian Oldenburg, Christopher Brown, Jeff Dunn, Joanne Aitken
Colorectal cancer (CRC) is the most common invasive cancer in Australia with a lifetime risk of one in 17 for men and one in 26 for women.1 In 2000 12 405 cases of CRC were diagnosed in Australia (age standardised rate 46.5 per 100 000) and there were 4718 CRC deaths (age standardised rate 16.8 per 100 000).
An audit of influenza vaccination rates
Patrick Byrnes, Barbara Fulton, Margaret Crawford
For elderly people, influenza vaccination confers significant benefits.1 Routine invitation by general practitioners to patients aged 65 years and over for free influenza vaccination is recommended.2
Excising basal cell carcinoma in general practice
Nicholas Bostock-Ling
Nonmelanoma skin cancer (NMSC) is the commonest type of cancer diagnosed in Australia, and accounts for more health expenditure than any other cancer.1,2
Book reviews
Christopher Beer, Ewa Piejko
Reviewed this month are Living with Alzheimer's and other Dementias and Midwife Wisdom, Mother Love
Are Perth metropolitan GPs prepared for common medical emergencies?
Jonathan Mole, David McGuire, Richard Riley, Neil Trewhella
General practitioners are the first point of contact for many acutely ill patients requiring emergency treatment.1,2 Although relatively infrequent, providing the correct treatment in a timely fashion may be crucial. Yet GPs are often inadequately prepared to deal with acutely ill patients, being limited mainly by the availability of emergency equipment (Table 1) and a lack of emergency drugs.3,4
Nonpigmented skin lesions - how many are nonmelanoma skin cancer?
Kristen L FitzGerald, Petra G Buttner, Shaun A Donovan
Nonmelanoma skin cancers (NMSC) are the most frequently diagnosed cancers in Australia and their incidence is increasing.1 Over 50% of the population
will develop an NMSC in their lifetime2 and 2% require treatment each year.3 This results in NMSC being the most expensive cancer to treat.4