BEST PRACTICE 25 DECEMBER 2009 Infectious gastroenteritis Generalised anxiety disorder HIV bpac nz Smoking associated cancers better medicin e Editorial Team Tony Fraser Professor Murray Tilyard We would like to acknowledge the following people for Clinical Advisory Group their guidance and expertise in developing this edition: Michele Cray Dr Shaun Costello, Dunedin Serena Curtis-Lemuelu Dr Edward Coughlan, Christchurch Dr Rosemary Ikram Professor Tony Dowell, Wellington Dr Cam Kyle Dr Rosemary Ikram, Christchurch Dr Chris Leathart Mr William Pearce, Christchurch Dr Lynn McBain Dr Alan Pithie, Christchurch Adam McRae Dr Gabrielle Ruben, Wellington Janet Maloney-Moni Assoc. Professor Mark Thomas, Auckland Dr Peter Moodie Dr Robyn Toomath, Wellington Associate Professor Jim Reid Dr Neil Whittaker, GP Reviewer, Nelson Associate Professor David Reith Assoc. Professor Michael Williams, Dunedin Professor Murray Tilyard Programme Development Team Rachael Clarke Peter Ellison Best Practice Journal (BPJ) Rebecca Harris Julie Knight ISSN 1177-5645 Noni Richards BPJ, Issue 25, December 2009 Dr Tom Swire Dr AnneMarie Tangney nz Dr Sharyn Willis BPJ is published and owned by bpac Ltd Dave Woods Level 8, 10 George Street, Dunedin, New Zealand. Report Development Team Bpacnz Ltd is an independent organisation that promotes health Justine Broadley care interventions which meet patients’ needs and are evidence Todd Gillies based, cost effective and suitable for the New Zealand context. Lana Johnson We develop and distribute evidence based resources which describe, facilitate and help overcome the barriers to best Web practice. Gordon Smith Bpacnz Ltd is currently funded through contracts with PHARMAC Design and DHBNZ. Michael Crawford Bpacnz Ltd has five shareholders: Procare Health, South Link Management and Administration Health, IPAC, the University of Otago and Pegasus Health. Kaye Baldwin Tony Fraser Kyla Letman Professor Murray Tilyard SOUTH LINK HEALTH Distribution Lyn Thomlinson Colleen Witchall Contact us: Mail: P.O. Box 6032, Dunedin Email: [email protected] Free-fax: 0800 27 22 69 This magazine is printed on an environmentally responsible paper managed under the environmental management system ISO 14001, produced using Certified ECF pulp sourced from Certified Sustainable & Legally Harvested Forests. www.bpac.org.nz CONTENTS Assessment and management of infectious 10 gastroenteritis Every year around 200,000 New Zealanders acquire a food associated illness. Gastrointestinal diseases account for the majority of all disease notifications in New Zealand. The majority of cases of infectious gastroenteritis are self-limiting and most people do not seek medical attention. When people do present, the key clinical issue is the prevention of dehydration. Empirical use of antibiotics is not usually indicated. Generalised anxiety disorder in adults – diagnosis 20 and management Anxiety disorders are the most frequently seen mental disorder in general practice and generalised anxiety disorder (GAD) is one of the most common types. GAD is often seen in people who also have major depression. Psychological and drug therapies are equally effective in the treatment of GAD but the relapse rate for psychological therapies may be lower. Selective serotonin re-uptake inhibitors are the first line option for drug treatment of GAD. Non-occupational exposure to Human 28 Immunodeficiency Virus (HIV) Rates of HIV infection are increasing in New Zealand, especially among men who have sex with other men. GPs are often the first point of contact for people who have been exposed to HIV. Referral to an infectious disease specialist for post exposure prophylaxis may be appropriate in some cases. Regular HIV testing should be considered as a routine aspect of healthcare for people at risk of HIV exposure. BPJ | Issue 25 | 1 CONTENTS 36 Smoking related cancer morbidity and mortality Smoking contributes to approximately one in three cancer deaths in New Zealand. Early detection and referral of smoking related cancers The majority of people with cancer will initially present to general practice, therefore GPs have an excellent opportunity to make a difference with early detection and the initiation of speedy referral to specialist services. However, the difficulty is to achieve improved cancer detection without increasing unnecessary referrals, which may reduce access to services for people who need them. Spotlight on lung cancer Lung cancer is the fifth most common cancer in New Zealand, however it is the leading cause of cancer mortality in men and the second highest cause in women. Recognising lung cancer early is the key. Supporting the PHO Performance Programme 2 | BPJ | Issue 25 CONTENTS Essentials 4 Christmas message 6 Upfront The big issue – discussing weight loss in general practice 50 Practice snippets Aspirin for prevention of cardiovascular disease • Paracetamol used post-vaccination 53 Correspondence Oxycodone All web links in this journal can be accessed via the online version. www.bpac.org.nz The information in this publication is specifically designed to address conditions and requirements in New Zealand and no other country. BPAC NZ Limited assumes no responsibility for action or inaction by any other party based on the information found in this publication and readers are urged to seek appropriate professional advice before taking any steps in reliance on this information. BPJ | Issue 25 | 3 It’s better to give than to receive… A Christmas message It’s better to give than to receive receiving support. At the end of the study, depression and It is good to be good to others. Of course virtue has its mood were improved, but what surprised researchers was own reward, but doing something good for someone else that the women in the support group survived twice as can have benefits that are both psychological and physical. long as the women without support (18 months compared There is even scientific evidence to back this up. with nine months). Being altruistic is associated with a longer life expectancy. People employed in helping professions, such as healthcare Several longitudinal studies of older adults have found that professionals, have a head start in reaping the rewards of volunteering results in significant reductions in mortality. giving. In addition, socially connected people generally outlive those who lead more isolated lives. It’s the thought that counts The power of positive thinking Philanthropy works too. Making a monetary donation activates an area in the brain that is responsible for If all this do-gooding sounds like it takes too much dopamine-mediated euphoria – secret Santa anyone? effort, there is still hope. Just thinking about giving may be enough to reap the benefits. The “Mother Teresa” Helping others is often a necessary step in helping study demonstrated that physiological changes occur in yourself. Researchers have found that recovering response to virtuous thoughts. After viewing a film about alcoholics, who help other alcoholics to achieve Mother Teresa’s work, a group of students displayed sobriety, are significantly less likely to relapse increases in immunoglobulin A, a protective antibody. in the year following treatment. These increases were significantly higher than those who watched a neutral film. Levels remained high for an hour In another study, women with after the film, and the researchers concluded that dwelling breast cancer were assigned on positive thoughts strengthened the immune system. to a support group, to test whether this improved mood and But don’t think bad thoughts rates of depression. A cautionary tale for the Ebenezer Scrooge’s among us Participation in the – people who dwell on negative thoughts, or only think of group included themselves, are more likely to develop illness at an earlier both giving and age. 4 | BPJ | Issue 25 “The value of a person resides in what they give and not in what they are capable of receiving”. – Albert Einstein All good things come to an end In a study of people with Type A personalities, high numbers of self-references in speech significantly So the good news is that it’s good to be good and thinking correlated with heart disease, after controlling for age, about being good might be good enough. However it’s bad blood pressure and cholesterol. to be bad, but it’s also bad to be too good. Hostility and negative emotional states among married Let’s apply the “giving and receiving” theme to some of the couples are associated with longer times for wound articles in this edition: healing. In one study, wounds took a day longer to heal after an argument than after a supportive discussion, Infectious gastroenteritis and two days longer in those demonstrating high levels It’s better to give food than to receive it. Beware of the of hostility. Christmas buffet, know where your food has been and how it has been prepared. Like your mother always told you, the Bad bedside manner catches up with you in the long run. safest option is the dish you brought yourself. In a historical study of doctors at Duke University, hostility scores based on hostile emotions, attitudes and actions Discussing weight loss were calculated at age 25 years. At age 50 years, those It’s better to give advice to your patients, rather than to who previously scored highly on the hostility scale, were fear receiving criticism because you are not perfect either. four to five times more likely than those with lower scores, It’s about the patient and how you can help them. In the to develop coronary disease and seven times more likely process you may discover that you have climbed some of to die of any disease. that hill to success yourself. HIV and risky behaviours Eat, drink and be merry It’s better to give…now here it gets tricky on how to stay But all things in moderation polite. Read the article and make your conclusions about risky behaviours and how to counsel your patients. It is good to be good to others…but not too good.