Journal Round Up – Q3 2019

a) Medical Republic
! Diverticulitis: Mild case – clear liquid diet rather than Abx; CT best modality to diagnose
! Use MCC to stratify cases of tonsilitis re Abx
! Introduce all allergens >12m even with Fx – monitor closely
! Stem cell joint injections for OA – not recommended by any College
! Two new mAb therapies for recalcitrant asthmatics – Il-5 binders – from specialists
b) MJA – July / Aug / Sept 2019
! HRT
− Absolute contraindications: hormone sensitive cancer; undiagnosed vaginal bleeding
− Relative (use transdermal): CVD; VTE; liver disease; migraine with aura
− AEs and benefits
• Breast cancer: extra 1 case in 1000 taking P containing HRT; reduced if O used too
• CVD: if started <10yrs post-menopause or <60yo, 48% reduction (nil effect stroke)
• VTE: only if oral
− Treatment (need P if uterus intact)
• <12m since menopause: constant O + cyclical P or Mirena
• >12m: continuous O/P; or oral O + SERM; or tibolone
• Check AMS website for options
• Titrate O: reduce if breast tenderness, increase if poor symptom management
− Duration
• IMS: nil mandatory limit on treatment (lose CVD/CVA benefits)
• Most will have symptoms for 8 years, 20% into 60s/70s
− Other treatments
• Can try 4 weeks of escitalopram / paroxetine
− Topical vaginal oestrogen
• Effect on uterus not completely settled: use P or ensure endometrial monitoring
! Rhesus factor – 2 doses of Anti-D is better than 1.
c) AJGP July / Aug / Sept 2019
! Microbial keratotis
− do not use antimicrobial eyedrops prior to ED ophth review – will affect MC&S – IMMEDIATE
review
! Childhood melanoma ABCDE:
− Amelanotic; Bleeding or Bump; Colourless or Colour uniformity; De novo appearance or Diameter
<6mm; Evolution
! **Wound care**
− “Golden window” of <8 hours overrated per Cochrane as long as aDT given as required
− Onset if lignocaine is <2 mins and lasts ~ 1 hour (2-6h if + adrenaline) - use ~1 cm around wound
via skin breach
− Irrigate with NS only – no chlorhex / povidone etc – impairs healing. Tap water irrigation is
actually OK – per Cochrane
− Use Chlorhex for the surrounding skin prior to suturing
− Refer if:
• Damage ot underlying structure; contamination +++; poor opposition due to tissue loss;
cosmesis; wound to large to anaethetise
− Skin glue
• Oppose edges (NIL GLUE IN WOUND), apply layer 5-10mm each side, leave to dry 15 secs,
add two (2) more coats – will peel off in 5-17 days do NOT put Chlorhex on the glue
• Can use Stristrips prior to ensure initial good opposition
! ***Burns in Children*** - applies to adult burns too
 −When to refer
• Hands / face / genitals / across joints; chemical; electrical; trauma; inhalation; circumferential;
significant co-morbidities; non-accidental; age < 1 year old; nil healing <7 days; >10%TBSA
• Any worse than epidermal / superficial dermal (ie if not painful / nil hairs follicles / dark pink or
blotchy / brown / black)
− Management: General
• 20 mins under tap
• Blisters: nil consensus – debride if non-viable, causing pain or movement limitation – snip top
• Antibiotics only is appears infected – swab also
• After healing: ensure wound is moisturized, non soap cleanser, sunscreen
− Dressings
• Aim is to ensure healing <14d – scarring ++ if continues beyond this
• Ensure patient uses analgesia prior to changing dressing
• Superficial burns: Mepilex +/- Ag foam – leave on for 5-7 days – (48h only if silver)
• Superficial -> Mid dermal: ActviHeal / DuoDerm Hydrocolloid – leave for 3- 5 days
• Always review after 48 hours then every 2-3 days
! Acute laceration suturing
− Interrupted works in most situations
− Cutaneous – use non absorbable
− Face, limbs, scalp: 5-0; Torso 4-0
− Debride ragged edges; undermine with snipping
− Keep dry and covered at least 24 hours; then moisturize with Chlorsig
− Face: 3-5; Scalp/Arms 7-10; torso/legs/back of hands and feet: 10-14; soles / palms: 14-21

d) Diabetes Management Journal

! Diabetic CKD
− SGLT2 inhibitors also improve renal fx alongside ACEi / ARB (check EUC 2-3w after initiation)
− Evaluate with BP / ACR -> Low, med, high risk (renal referral if high)
− Aim SBP< 120 if tolerated

Recent guideline update – eTG

a) Acute gout
! 1st line
− local CS injection into up to 2 affected joints; Prednisone 15-30mg until symptoms abate (3-5
days); NSAIDs (any) upper end of range 3 – 5 days
! 2nd line
− Colchicine 1mg stat then 500microg 1 hour later