Latest news with #primaryCare
Medscape
23-05-2025
- Health
- Medscape
GPs Urged to Improve Skin Cancer Care with Dermoscopy
BIRMINGHAM — Primary care professionals were urged to use dermoscopy and consider further training in minor skin surgery during the Primary Care Show 2025, amid a sharp rise in skin cancer cases across the UK. Speaking at the event, dermatology clinical nurse specialist Julie Van Onselen said skin cancer has been called 'the new epidemic of healthcare'. She encouraged GPs to be more proactive in identifying and managing skin lesions. A Growing Health Burden Recent data show there were 224,092 cases of skin cancer recorded in England in 2019. Of these, 15,332 were melanomas. Of the 208,760 non-melanoma skin cancer (NMSC) cases, 74% were basal cell carcinomas (BCCs), 23% were squamous cell carcinomas (SCCs), and 2% were rarer types of skin cancer. Cancer Research UK data show the highest incidence rates are among older adults. More than a quarter (29%) of new melanoma cases in the UK and 48% of new NMSCs occurred in individuals aged 75 and over. Clinical Vigilance in Primary Care 'We have to recognise all skin cancers early and treat them,' Van Olsen said. 'Particularly for melanoma, which is 4% of all new skin cancers and the fifth most common cancer now in the UK. If you can recognise an early melanoma, you can save lives – and that's what's so important.' Van Olsen added that all primary healthcare professionals 'have a responsibility to be able to assess skin and particularly be alerted to any lesion of concern that we should then discuss with a colleague, or think about referral'. There were many skin changes that did not necessarily require medical attention but could bother a patient enough for them to ask their clinician about it. This might happen as an aside remark from a patient as they walked out of the door, Van Olsen told Medscape News UK . 'Even though dermatology is seen to be a specialist field, it's not. It's a generalist subject because for 20% of people who come for primary care consultations, it's skin related,' she said. 'When you examine somebody who comes in with a lesion, the first thing you need to do is take a really good clinical history. You need to examine, and one of the key things is that it's not really good enough just to look at the actual mole or the changing lesion. You need to try and examine as much of the skin as possible.' Dermatoscopes: A Key Diagnostic Tool Van Olsen, who has been working in the dermatology field for more than 30 years and is executive committee member of the Primary Care Dermatology Society (PCDS), encouraged healthcare professionals to learn dermoscopy if this was not already part of their skillset. 'It will really help you recognise normal lesions and detect lesions of concern, early,' she said. A dermatoscope 'is as useful a tool to the skin as the stethoscope to the chest, the auroscope to the ear, and the ophthalmoscope to the eye,' she said. 'I think everybody — every healthcare professional in primary care — should use one.' Dermoscopy enables a much more thorough evaluation of the skin, right down into the dermal layer. For those not familiar with using a dermatoscope, Olsen recommended referring to the guide published on the PCDS website and information on the society's YouTube channel . The PCDS also runs a course for beginners. Recognising Red Flags Among 'red flags' for skin lesions are rapid growth, pain or soreness, and bleeding. Look for recent changes in the size, shape, and symmetry of the lesion, Van Olsen advised. If a lesion 'wobbles, it's soft, it squishes', blanches, or looks like it has a crumbly and rough surface, then it could be benign. Asymmetry, irregular borders, and multiple colours are warning signs for melanoma. 'I sometimes say to patients, if your mole was a pizza and we cut it in four and all your friends got the same slice, we'd be happy. If they all got different toppings, that would mean the pattern would not be symmetrical,' she told her audience at the meeting. The A in 'asymmetry is the first component of the ABCDEF lettering system for recognising possible melanoma. B stands for border, with irregularity being concerning; C is for colour, where three or more colours are a worry; D is for diameter, where a lesion larger than 6 mm is suspect, and E if for evolving, meaning there is growth or change. F stands for 'funny looking'. Be on the lookout for the 'ugly duckling sign': anything that is out of the ordinary or looks unusual to you, even if the patient indicates that nothing had changed, Van Olsen advised. Also in use is the EFG system, standing for elevated, firm, and growing. All of these factors need to be present for the lesion to be considered concerning. 'If in doubt, check it out', Van Olsen stressed. Expanding Skin Surgery in Primary Care Delegates also heard from Dr Miles Scholar, who highlighted the potential for GPs to perform minor skin surgeries, such as removal of low-risk BCCs. Dr Miles Scholar 'We're drowning in skin cancer in this country now,' noted Scholar, a senior GP partner at Witley and Milford Medical Partnership in Witley and associate specialist plastic surgeon at The Royal Surrey County Hospital in Guildford. 'Everybody's waiting lists are crammed, and quite regularly we are seeing patients wait from 9 to 12 months to have the surgery for basal cell carcinoma,' he told Medscape News UK . Scholar observed that unlike melanoma or SCCs, BCCs tend to be slow growing. However, if untreated, they can become destructive and require complex surgery. Scholar called for a streamlined process to allow surgically inclined GPs to manage low-risk BCCs. This would 'relieve that pressure on the hospitals so they can concentrate on the more difficult things, like the squamous cell carcinomas, the melanomas, and the rare skin tumours, which obviously need a lot more input'. Mixed Support from Secondary Care While some secondary care providers were likely to be open to GP involvement, support from trusts was 'patchy', Scholar admitted. He attributed resistance to skin tumour guidelines from the National Institute for Health and Care Excellence which were published almost 20 years ago. At that time, it was not recommended for GPs to be operating on skin cancer. However, he believes the landscape is changing. 'There is a perception that certainly these low-risk skin tumours, like basal cell carcinoma, can be dealt with by GPs safely, as long as [the BCCs] fulfil certain criteria and the GPs themselves are adequately trained and regulated.' 'There's more than enough for everybody to do,' he added, noting that the NHS is 'a collaborative organisation – so, seeing ways that everybody can improve the nation's health, overall, is important'. Van Onselen and Scholar declared no conflicts of interest.
Medscape
20-05-2025
- Health
- Medscape
Improving End Organ Checks in Outpatient Hypertension
Providers should evaluate all patients with new-onset hypertension for evidence of end organ damage, guidelines say, but researchers have found gaps in that process. Researchers at Indiana University School of Medicine's Southwest Internal Medicine Residency Program, including Mark Georgy, MB BCh, presenting author, noted that new-onset hypertension is commonly diagnosed in the outpatient setting by primary care providers. Organ dysfunction secondary to hypertension was not being monitored appropriately at their own outpatient residency clinic, so they suspected that may be the case elsewhere. The team set out to find a way to improve the evaluation of end organ damage and presented their findings in a poster at Society of General Internal Medicine (SGIM) 2025 Annual Meeting in Hollywood, Florida. First, they looked at why the end organ evaluations weren't being done and found that unfamiliarity with the most recent guidelines was a significant factor, followed by lack of resources in the clinic that providers could easily reference. A lack of streamlined order sets within the electronic medical record (EMR) was also an issue. Multipronged Intervention The researchers developed 30-minute interactive seminars for small groups of residents and created and printed posters detailing algorithms and made them readily available in multiple areas of the resident clinic work area. They also developed an order set for the EMR that included all the workup required to evaluate end organ damage according to guidelines. Their measures of success were increases in evaluating end organ damage and, through survey responses, how the resources were received by residents and attending physicians. While the qualitative results were not available by the poster deadline, the authors wrote, the survey responses show the intervention was well received. They added that their approach was designed to allow other programs to easily replicate the steps. 'Most complimented have been the interactive seminars, with most noting the wealth of useful knowledge gained in an engaging yet efficient format. Posters were deemed easy to interpret and a useful tool to reinforce knowledge,' the authors reported. 'The order sets were found to make workflow more streamlined.' Complex Guidelines May Feed Problem Donald DiPette, MD, clinical professor of internal medicine at University of South Carolina School of Medicine Columbia, told Medscape Medical News the lack of end organ damage evaluation in hypertension is a common gap in care far beyond the group studied here. He said the number and length of guidelines may well contribute to the gap and make it difficult for primary care physicians to easily access guidance on best practices. Additionally, he said, it's also common to not act on the signs of end organ damage even after it is identified. Reasons for that are that the guidelines 'are overly comprehensive and that makes them overly complicated,' he said. 'Even the executive summaries are overly complicated. Most guidelines are written by subspecialists and not necessarily aimed at the primary care physician.' What's Missed Without the Evaluation DiPette explained the need for the end organ evaluation. The elevated pressure damages primarily the heart, the brain, and the kidneys. It's a vicious cycle, DiPette said, because 'if you develop the end organ damage either from the hypertension or another disease that causes the end organ damage, that damage can further elevate the blood pressure. One of the reasons the evaluation is so important is to break that cycle.' Finding the end organ damage may also change the level of blood pressure physicians treat. 'In most of the guidelines now, if you have end organ damage like heart disease or kidney disease or diabetes, you would treat patients at a lower blood pressure level,' he explained. That, in turn, changes the target blood pressure you want to achieve. It also might influence the medications you choose, DiPette said. 'Some of the blood pressure medicines can lower blood pressure and help the organ,' he said. 'There also may be medications you want to add to further treat the patient's organ damage at the same time you're lowering the blood pressure.' He said these researchers are 'likely onto something' with their intervention. 'I like their idea of utilizing the electronic medical records,' DiPette said. 'We often are pretty critical of electronic medical records as physicians, but there's really some positive benefits of an EMR and this is one of them.' 'Any positive acknowledgment of the problem and ways to address it brings the issue to light.' Then professionals are more likely to not only investigate for the presence of end organ damage but also act upon it, he said. DiPette declared having no relevant financial relationships. He was part of a leadership team that developed World Health Organization guidelines on hypertension. Authors reported having no relevant financial relationships.
Medscape
19-05-2025
- Health
- Medscape
The Three Key Steps to Diagnose Dementia in Primary Care
This transcript has been edited for clarity. Today we're going to discuss a new clinical practice guideline from the Alzheimer's Association on the evaluation and testing for Alzheimer's and related dementias. This is an important area for us in primary care because we are the first clinicians that most patients see when they are concerned they may be having memory problems or dementia symptoms. It's a challenging area and this document provides much-needed guidance. The Alzheimer's Association clinical practice guideline for the Diagnostic Evaluation, Testing, Counseling, and Disclosure of Suspected Alzheimer's Disease and Related Disorders (DETeCD-ADRD) recommends a three-step approach to diagnosis. The first step is to assess whether there's a cognitive deficit. If there is a cognitive deficit, then assess whether that deficit fits mild cognitive impairment (MCI) or whether it fits mild, moderate, or severe dementia. Remember the main difference between MCI and dementia is that dementia, by definition, interferes with the capacity for independent everyday activities. It's important to get a history from both the patient and a significant other, with attention to activities of daily living, time course of the cognitive decline, and any potential precipitating factors. Patients themselves may not always give the best personal history to provide a complete picture of what's going on, due to factors such as memory impairment, embarrassment, or a lack of self-awareness. In addition, the DETeCD-ADRD guideline recommends performing a mental status exam using a validated instrument like the Montreal Cognitive Assessment or the Mini Mental State Examination. If that evaluation shows that the patient is cognitively unimpaired, then no further evaluation is needed and we can educate the patient about brain healthy behaviors and, of course, plan for follow-up assessment. If the patient does show evidence of cognitive impairment, then it's important to define the effect of that impairment on the patient's function. The second step in the evaluation is to characterize the clinical profile of a patient's cognitive-behavioral syndrome. What this means is that we want — to the degree that is reasonable — to delineate the domains of impairment, which might include memory, executive function, attention, language, and emotional and social functioning. Here's where neuropsychological testing can be helpful, if it's available. These first two steps allow us to develop a plan for personalized care and support. The third step is testing to help figure out the cause of the patient's symptoms. It's important to differentiate Alzheimer's disease from Alzheimer's disease–related dementias (ADRD), such as frontotemporal dementia, Lewy body dementia, multi-infarct or vascular dementia, or mixed vascular and Alzheimer's dementia. It's also important to determine if the cognitive decline is caused by or being made worse by other diseases like depression, sleep apnea, and B12 deficiency or if other factors like the effect of medications (eg, anticholinergics and alcohol) are contributing to the cognitive or behavioral symptoms. Step 3 of the evaluation includes ordering what the guidelines refer to as 'tier 1 laboratory studies.' They are first tier because these are laboratory studies that are considered routine and should be ordered for all patients who have MCI or dementia. The recommended labs should include a complete blood cell count with differential, complete metabolic panel, erythrocyte sedimentation rate, and tests for thyroid-stimulating hormone, vitamin B12, homocysteine, and C-reactive protein levels. In addition, the DETeCD-ADRD guideline recommends that physicians order imaging, preferably a brain MRI without gadolinium or, if MRI is contraindicated, a noncontrast head CT. The MRI can rule out tumor, show multiple infarcts, or show regional atrophy patterns that may suggest specific neurodegenerative pathologic changes — but it's important to recognize that the MRI is not in any way diagnostic. The guideline recommends against using the term 'labs for reversible causes of dementia' because the labs only rarely uncover a cause for dementia that is reversible. The guideline authors cite a meta-analysis that showed less than 1% of dementia syndromes are reversible, but nearly 10% of people with dementia have a common comorbid condition that may be contributing to their decrement in cognitive function. This certainly fits my experience. The preferred term for tier 1 labs is a 'cognitive lab panel.' Additional testing, termed tier 2 and 3 tests, are only recommended when necessary on an individual basis. These can include sleep studies and antinuclear antibody, folate, ammonia, lead, Lyme antibody, rapid plasma reagin, and HIV tests. Of course, there are plenty more tests that can be done in specific circumstances. Now what's missing here? How about blood biomarkers for Alzheimer's disease? I recently reviewed the Alzheimer's Association workgroup recommendations on revised criteria for diagnosis and staging of Alzheimer's disease. The key principle which that guideline lays out is that Alzheimer's disease is defined by its biology — neuropathologic changes in the brain, like deposition of amyloid and tau protein. We are now on the cusp of having blood-based biomarkers for amyloid beta and p-tau that will enable us to either rule in or rule out Alzheimer's disease with a high degree of accuracy. It's important to recognize that while the biomarkers are promising and will be incredibly useful, they still need to be further validated in large populations. And although the blood biomarkers can now be ordered through many lab tests, there is not yet a biomarker that is fully approved by the US Food and Drug Administration. In my opinion, start to understand the place of blood biomarkers now, because once they are regulatory approved, they'll become a routine addition to the initial panel of laboratory tests that we typically order when evaluating patients for dementia. Finally, I was thrilled to see that the guidelines specifically acknowledge that in the primary care setting, two or more problem-focused visits would usually be required to assess for dementia. I certainly find that to be the case. When there's uncertainty with regard to diagnosis, early age of onset, rapid progression, and/or consideration of biologic therapy, then referral to a dementia specialist makes sense. This is an important update and it provides a clear, straightforward approach which allows us to evaluate patients for dementia with confidence. I'm interested in your thoughts, please leave them in the comments section below. For Medscape, I'm Dr Neil Skolnik.
