nodules How I approach thyroid · 15/10/2020 · Improved feedback pathway for WACHS services ....
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June 2019 - In brief June 2019 - In Brief For links to resources, clinical updates and more, visit news.wapha.org.au History: Important features are family history of thyroid cancer, and exposure to radiation. Exposure to radiation may be from radiotherapy for breast or neck cancer, or general exposure such as associated with nuclear disaster. Thyroid function: Test TSH, and if low add T4 and T3. Cancer nodules rarely produce thyroid hormones. Therefore, if a patient has a low TSH the next step is a thyroid uptake scan (not biopsy). If the nodule is hot it can be assumed to be benign without biopsy. I also do thyroid autoantibodies as it is useful to know if patients have high antibody levels (such as with autoimmune thyroid disease) as they will often have a lymphocytic cellular picture on FNA. Thyroid nodules are common. They are found in two to six percent of the general population by palpation and 19 to 35 percent by ultrasound. They are frequently picked up when patients are having investigations for other reasons, including by carotid dopplers, MRI, CT and PET scan. Whether they are picked up incidentally or present with symptoms, they all need to be assessed. There are three ways nodules cause problems; autonomous production of thyroid hormones causing hyperthyroidism, compressive symptoms if very large (and retrosternal), and thyroid cancer. Each nodule is said to have a five to eight percent chance of malignancy. This is how I would work up a new thyroid nodule: 1. 2. How I approach thyroid nodules by Dr Vijay Panicker Head of Department Endocrinology, Sir Charles Gairdner Hospital Ultrasound: There are features on ultrasound that can stratify the risk of the nodule and will therefore dictate whether and what size it should be biopsied. A good thyroid radiologist will report these and often rate the risk of the nodule according to one of the rating systems (such as ACR-TIRADS). If the size and important features of the nodules >1cm are not reported I suggest you contact the radiologist. Fine needle aspiration (FNA): Should be done if the ultrasound appearances are sufficiently worrying and the nodule is large enough. If the nodule is easily palpable the pathologists can do this and ensure they get a good sample. Otherwise it is done under ultrasound guidance. It is important to counsel the patient that 15 to 35 per cent of these come back indeterminate; due to lack of sample, too bloody, etc. It is therefore important to know what the risk is before biopsy to guide you if the biopsy is unsuccessful (i.e. should you re-biopsy, operate or observe). 1. 2. Benign FNAs are 98 to 99 per cent accurate and can be left, although my practice is to repeat an US (and TFTs) if the nodule was very large or had suspicious features. If FNA is malignant (or suspicious of malignancy), refer to a thyroid surgeon for thyroidectomy. 15 October 2020 Continued page 2 3 4
Transcript of nodules How I approach thyroid · 15/10/2020 · Improved feedback pathway for WACHS services ....
June 2019 - In brief June 2019 - In Brief
For links to resources, clinical updates and more, visit news.wapha.org.au
History: Important features are family history ofthyroid cancer, and exposure to radiation.Exposure to radiation may be from radiotherapyfor breast or neck cancer, or general exposuresuch as associated with nuclear disaster. Thyroid function: Test TSH, and if low add T4 andT3. Cancer nodules rarely produce thyroidhormones. Therefore, if a patient has a low TSHthe next step is a thyroid uptake scan (not biopsy).If the nodule is hot it can be assumed to be benignwithout biopsy. I also do thyroid autoantibodiesas it is useful to know if patients have highantibody levels (such as with autoimmune thyroiddisease) as they will often have a lymphocyticcellular picture on FNA.
Thyroid nodules are common. They are found in twoto six percent of the general population by palpationand 19 to 35 percent by ultrasound. They arefrequently picked up when patients are havinginvestigations for other reasons, including by carotiddopplers, MRI, CT and PET scan. Whether they arepicked up incidentally or present with symptoms, theyall need to be assessed.
There are three ways nodules cause problems;autonomous production of thyroid hormones causinghyperthyroidism, compressive symptoms if very large(and retrosternal), and thyroid cancer. Each nodule issaid to have a five to eight percent chance ofmalignancy. This is how I would work up a newthyroid nodule:
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How I approach thyroidnodulesby Dr Vijay PanickerHead of DepartmentEndocrinology,Sir Charles Gairdner Hospital
Ultrasound: There are features on ultrasound thatcan stratify the risk of the nodule and will thereforedictate whether and what size it should bebiopsied. A good thyroid radiologist will reportthese and often rate the risk of the noduleaccording to one of the rating systems (such asACR-TIRADS). If the size and important features ofthe nodules >1cm are not reported I suggest youcontact the radiologist. Fine needle aspiration (FNA): Should be done if theultrasound appearances are sufficiently worryingand the nodule is large enough. If the nodule iseasily palpable the pathologists can do this andensure they get a good sample. Otherwise it isdone under ultrasound guidance. It is important tocounsel the patient that 15 to 35 per cent of thesecome back indeterminate; due to lack of sample,too bloody, etc. It is therefore important to knowwhat the risk is before biopsy to guide you if thebiopsy is unsuccessful (i.e. should you re-biopsy,operate or observe).
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Benign FNAs are 98 to 99 per cent accurate and canbe left, although my practice is to repeat an US(and TFTs) if the nodule was very large or hadsuspicious features. If FNA is malignant (or suspiciousof malignancy), refer to a thyroid surgeon forthyroidectomy.
15 October 2020
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08 6272 4900 | [email protected] | www.wapha.org.au
Note that most early recurrences are due toincomplete resection rather than rapid recurrenceand therefore I only refer to high volume thyroidsurgeons.
A follicular neoplasm or suspicious follicularneoplasm needs referral to a surgeon forhemithyroidectomy as cytology cannot distinguishbetween follicular adenoma and follicular carcinoma.The majority will still be benign. Indeterminant lesionsare best referred to a thyroid surgeon orendocrinologist, as it is worthwhile considering thepre-test risk (history, ultrasound features) andpatient anxiety to decide if further biopsy or surgeryis the next best option.
I tell patients that > 90 per cent of thyroid cancersare differentiated thyroid cancers of which 95 percent have very good prognosis (slow growing, slowspreading and don’t shorten life expectancy). There istime to clarify the diagnosis (such as waiting torepeat biopsy) and I tend to err on the side ofconservatism to avoid unnecessary surgery, which israrely the case with other malignancies.
Finally, there is no value in evaluating nodules <1 cmexcept in a very high-risk patient, or in measuringserum thyroglobulin in someone who has a thyroid.
See also the “Thyroid Nodules and Goitre”HealthPathway.
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Your existing bookmarks and links will continue towork but will be redirected, so for seamless use youmay wish to update them and/or re-download anydesktop or mobile icons and ensure your browser isup-to-date. See also instructions on how to downloada quick-link icon to your mobile android or iOS device,or how to add an icon to your desktop.
If you need any assistance with this transition or donot know your login details, contact theHealthPathways WA team on 08 6272 4926, or byemail at [email protected]
H o w I a p p r o a c h t h y r o i dn o d u l e s
Test drive the revised WA AHD form
The HealthPathways WA site is now mobile-friendlyand has migrated to a new domain. As a result, allpages shift and adjust the content depending on thedevice you are using (desktop computer, laptop,tablet, or mobile). This will ensure optimum accessto HealthPathways content no matter where you areconsulting from and may improve connectivity forthose whose practices have slow desktop internetspeeds. The “classic” HealthPathways site, withidentical content, is also still available (select aninterface preference by clicking on the three dots atthe top right of the screen on the new site).
Your normal login details or access method willcontinue to work, but you will need to log in again (ifyou haven’t already done so) due to the change indomain names.
The GP’s role in prevention ofbronchiectasis in Aboriginal children
GP Hospital Liaison Updates
“The GP follow up of Aboriginal children previouslyadmitted for chest infections is critical in providing thenecessary care to prevent bronchiectasis”, advises DrAndré Schultz.
It is important to follow up Aboriginal childrenhospitalised with chest infections. Acute lowerrespiratory infections (ALRIs) are the most commoncause of hospitalisations for Aboriginal childrenyounger than five years. A lesser known fact is thatapproximately 20% of Aboriginal children who arehospitalised with ALRIs infections such asbronchiolitis or pneumonia will go on to developchronic lung disease e.g. bronchiectasis.
That is why it is essential to ensure that Aboriginalchildren hospitalised with ALRIs are followed up.Follow-up a month after hospital admission isimportant to check for low grade respiratorysymptoms such as wet cough that has been presentsince the admission.
Chronic wet cough in this context is often a symptomof protracted bacterial bronchitis (PBB). PBB oftenoccurs in the absence of any other clinical symptomsor signs. Prompt and effective treatment of protractedbacterial bronchitis can prevent progression tobronchiectasis and prevent a life burdened withchronic disease.
The ‘Persistent Cough in Children’ HealthPathwaydefines PBB as “wet cough lasting for > 4 weekswithout specific pointers of an alternative cause, andwhich responds to antibiotic therapy”. PBB oftenrequires 2 to 4 weeks of antibiotic therapy and referralto a specialist if the cough does not resolve withtreatment.
08 6272 4900 | [email protected] | www.wapha.org.au
A free on-line training module on paediatricAboriginal lung health is available here. The moduleis endorsed by the WA Department of Health, theChild and Adolescent Health Service, the WACountry Health Service and other key healthinstitutions across WA. Dr Maree CreightonHospital Liaison GP,Perth Children’s [email protected]: Tuesday 9am-12pm and Wednesday12pm-5pm
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Tamsulosin (Flomaxtra)Silodosin (Urorec)Alfuzosin (Xatral SR)
Available only on the RPBS:
Dr Nigel DormerHospital Liaison GP , Osborne Park Hospital [email protected]
T h e G P ’ s r o l e i n p r e v e n t i o no f b r o n c h i e c t a s i s i nA b o r i g i n a l c h i l d r e n ( c o n t )
P r o s t a t e a n d b l a d d e r d r u gc h a n g e s a t O P H a n d S C G Hp h a r m a c i e s
Tamsulosin and Duasteride (Duodart) - StreamlineAuthorityDutasteride (Avodart) Authority or StreamlinedPrazosin OxybutyninPropantheline (Pro-Ban)Imipramine, Nortriptyline, and Amitriptyline
Osborne Park Hospital & Sir Charles Gairdner HospitalUrology are no longer providing subsidisedprescriptions of the following non-PBS prostate andbladder medications and patients will no longer beable to obtain them from the SCGH or the OPHPharmacy: tamsulosin (Flomaxtra), finasteride(Proscar), solifenacin (Vesicare) and mirabegron(Betmiga).
Other medications that are available on the PBS andRPBS include:
N e w S C G H F r a i l t y R a p i dA c c e s s C l i n i c
A new geriatrician clinic is starting at Sir CharlesGairdner Hospital (SCGH) and accepting referrals fromMonday 19 October 2020.
The Frailty Rapid Access Clinic (FRAC) is an innovativenew outpatient clinic being offered by the SCGHDepartment of Rehabilitation and Aged Care. Thisclinic is for patients who would benefit from rapidgeriatrician outpatient review, to avoid hospitaladmission. The clinic accepts referrals via CentralReferrals Service (CRS), for patients over 65 yearsresiding in the SCGH catchment.
FRAC aims to address the frustrating problem ofhospital clinic wait times which can be weeks tomonths, leaving an area of unmet need. FRAC willprovide an outpatient appointment with a geriatricianwithin seven days of receiving a referral, aiming todeliver fast, outpatient medical and multidisciplinarycare to higher acuity older patients with GeriatricSyndromes.
Patients referred to the clinic will benefit fromcomprehensive geriatric assessment andMultidisciplinary care personalised to their needs. Theclinic will work alongside the department's usual FallsClinic, Memory Clinic and Continence Clinic services.
Please direct referrals to the FRAC Geriatrician Clinic,SCGH Department of Rehabilitation and Aged Care,via CRS. Queries about FRAC can be directed to DrSarah Bernard, Geriatrician, Department ofRehabilitation and Aged Care, SCGH 6457 2594.
Dr Christine PascottHospital Liaison GP, Sir Charles Gairdner [email protected]
To improve feedback pathways for GPs and otherexternal service partners, WA Country Health Service(WACHS) has now completed updates to their website.
This feedback page can be easily reached via anypage on the WACHS website by clicking on theFeedback On Our Services icon, or by emailing:[email protected].
I m p r o v e d f e e d b a c k p a t h w a yf o r W A C H S s e r v i c e s
It's WA Mental Health Week, and WA PrimaryHealth Alliance is again partnering with the WAAssociation for Mental Health to sponsor MentalHealth Week. Key to this is the provision ofpromotional postcards throughout WA communitiesencouraging people to talk their GP about theirmental health.
Practices can access social media posts and otherresources to download and share atthesocialpresskit.com/see-your-gp. For moreinformation and to find out other ways to getinvolved, visit mentalhealthweek.org.au/
If a GoPC clinical document is available to view in MyHealth Record, you can discuss the document with thepatient, their family and / or carers. This supportsongoing shared decision-making with the patient, andprovides a starting point for advance care planningconversations should this be appropriate.
For more information on the upload of GoPC clinicaldocuments to My Health Record please email anyqueries to [email protected]
For more information on My Health Record includingthe uploads of Advance Care Planning documentsplease contact the WA Primary Health Alliance theemail any queries to the Digital Health Team [email protected]
For more information about Advance Care Planning,see the “Advance Care Planning" HealthPathway.
S e e y o u r G P a b o u t m e n t a lh e a l t h
08 6272 4900 | [email protected] | www.wapha.org.au
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Until recently, the Australian Immunisation
Register (AIR) used information from Medicare to
record whether a person identified as Aboriginal or
Torres Strait Islander.
Vaccination providers can now record this
information directly on the AIR which can help to
identify and give the clinically correct vaccination
schedule.
For more information visit:
https://www.health.gov.au/news/recent-updates-
to-the-australian-immunisation-register
I d e n t i f y i n g a s A b o r i g i n a l o rT o r r e s S t r a i t I s l a n d e r o n t h eA I R
South Metropolitan Health Service and WA CountryHealth Service recently commenced uploading Goalsof Patient Care (GoPC) clinical documents to MyHealth Record. When a GoPC clinical document iscreated during a person’s hospital admission, theyare asked if they would like the completed documentto be uploaded to their My Health Record. If theyagree, the document will be visible in their My HealthRecord.
This change means that completed GoPC clinicaldocuments can be viewed by the patient, their MyHealth Record representatives and other healthcareprofessionals involved in their care.
The WA Health sites that have recently enabled thisfunctionality are Fiona Stanley and Fremantlehospitals, and the WA Country Health Service SouthWest sites: Bunbury, Busselton, Collie, Warren andMargaret River. WA Health aims to roll out thisfunctionality to other sites over the next year.
If your patient has a GoPC clinical documentuploaded to the My Health Record, it will be in theplace where clinical documents are usually held. Thislocation depends on the type of clinical software youuse to access My Health Record. The document willbe listed as a ‘Goals of Care Document’.
G o a l s o f P a t i e n t C a r ed o c u m e n t s i n M y H e a l t hR e c o r d
08 6272 4900 | [email protected] | www.wapha.org.au
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C h a n g e s t o s e r v i c e s a n dr e f e r r a l p a t h w a y s f o r S J O GM i d l a n d P h y s i c i a n S e r v i c e s
St John of God Midland Public and Private Hospitalshas recently undertaken a review of public generalmedical outpatient clinics and sub-specialties andreferral pathways.
This will help SJOG to meet the ongoing and highdemand of urgent patient admissions, EmergencyDepartment referrals and those with significantclinical morbidity.
The criteria to accept referrals via the Central ReferralService (CRS) has been updated for the followingservices, effective immediately:
• Cardiology • Endocrinology and diabetes• General medicine • Infectious disease• Neurology • Renal Medicine GPs will be provided with the names of patients whoare currently on a waitlist that do not meet the newcriteria. In addition, patients will also be informed ofthis change and advised to discuss alternative optionswith their GP. Effective immediately, non-urgentreferrals should be referred to the CRS.
For a patient requiring immediate attention or advice,GPs should please call our GP Priority line on 9462 4222 and ask to speak to the Chief Registrar orConsult General Physician (available Monday toFriday between 8am and 5pm).
If you wish to discuss management advice for anindividual patient, please contact one of ourspecialists via our GP Priority line on 9462 4222.
For non-clinical queries relating to the changes,please contact Midland Physician Services PracticeDevelopment Manager, Catherine Milliner, [email protected] or 9462 4508.
The Health Workforce Scholarship Program (HWSP)is an initiative of the Australian GovernmentDepartment of Health to improve access to healthservices in rural and remote areas by helping healthprofessionals to pursue ongoing study anddevelopment.
Funding is available for health professionals whoprovide primary care services to Western Australianrural and remote Modified Monash locations in thefields of medicine, nursing, midwifery, dentistry orallied health, including Aboriginal health practitionersor workers. Training and upskilling of healthprofessionals must help meet an identified healthneed in the community.
For more information visitwww.ruralhealthwest.com.au/hwsp
Investigating symptoms of lung cancer: a guide forall health professionals
Diagnosis at an earlier stage of lung cancer leads tobetter outcomes for patients, however, diagnosinglung cancer can be challenging. Cancer Australia hasreleased a new evidence-based resource for healthprofessionals to support the optimal and timelyinvestigation of lung cancer symptoms - Investigatingsymptoms of lung cancer: a guide for all healthprofessionals.
The Guide outlines a systematic pathway for theappropriate investigation and referral of people withsymptoms or signs of lung cancer. It includes theoptimal timeframes for action at each step in thepathway and emphasises the importance ofmultidisciplinary care.
Download The Guide and watch the following videofor more information:
N e w C a n c e r A u s t r a l i ar e s o u r c e f o r t h ei n v e s t i g a t i o n o f l u n g c a n c e rs y m p t o m s
R u r a l H e a l t h W e s t H e a l t hW o r k f o r c e S c h o l a r s h i pP r o g r a m
08 6272 4900 | [email protected] | www.wapha.org.au
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A new report on general practice in Australia showsthat hypertension, low back pain, dyslipidaemia,depression and gastro-oesophageal reflux diseaseare among the most common issues dealt with ingeneral practice.
The third General Practice Insights Report,commissioned by the Australian GovernmentDepartment of Health and released by NPSMedicineWise, looks at around 2.9 million patients'de-identified data showing common chronic healthconditions in 2018-19 and aspects of the clinicalmanagement the patients received.
The report examines MedicineInsight data from theclinical software of participating general practicesand provides vignettes that show how theMedicineInsight data can be used to support qualityimprovements in clinical practice and health serviceplanning.
Visit www.nps.org.au/medicine-insight for moreinformation on the program.
G e n e r a l p r a c t i c e d a t a i si n f o r m i n g p o l i c y a n dr e s e a r c h t o i m p r o v e h e a l t ho u t c o m e s
Perinatal Anxiety & Depression Australia (PANDA)invites health professionals working in, or passionateabout, supporting peoples mental health and well-being to become a PANDA Clinical Champion.
Through clinical champions, PANDA is offering healthprofessionals an opportunity to broaden their impactand help us to build a community of passionateclinical leaders who work in or interact with the fieldof perinatal mental health. Clinical champions may beasked to consult on a range of PANDA outputs, frompublic health to service design and professionaldevelopment. Register here .
There is a “Perinatal Mental Health” HealthPathway.
O p p o r t u n i t y t o b e c o m e aP A N D A C l i n i c a l C h a m p i o n
N e w o n l i n e S T I T e s t i n g i nP r i m a r y C a r e l e a r n i n gm o d u l e
In recent years, the incidence of some STIs in WesternAustralia has been rising at an alarming rate. Thisyear a syphilis outbreak has been declared in metroPerth. It’s more important than ever for WesternAustralian primary care providers to screen and testfor STIs. Australasian Society for HIV, Viral Hepatitis andSexual Health Medicine's is pleased to announce anew online learning module, funded by and developedin collaboration with WA Health. Through interactivequizzes and case studies, Western Australian GPs andother health professionals can develop their skills toconfidently discuss sexual health with patients,conduct guideline-based STI screening and testing,and initiate contact tracing. The module is an accredited learning activity withRACGP and ACRRM, and a certificate of completion isavailable. Register at lms.ashm.org.au (search ‘STITesting’) Interested practitioners may also like to viewthe “Sexual Health” suite of HealthPathways.
D o n ’ t m i s s o u t o n f r e ea c c e s s t o t h e H e a r t H e a l t hC h e c k T o o l k i t
The delivery of Heart Health Checks in primary care isnow supported by Medicare. In April 2019, two newHeart Health Check items were introduced to theMedicare Benefits Schedule (MBS): Items 699 and 177.Eligible patients can now receive a Medicare rebatewhen they get a Heart Health Check from a GP (item699) or other medical practitioners non-vocationallyregistered (item 177) working in primary care. These MBS items support the assessment andmanagement of cardiovascular disease (CVD) risk inprimary care for eligible patients 45 years and over(30 years and over for Aboriginal and Torres StraitIslander peoples).
Register your interest to receive a copy of the HeartFoundation Heart Health Toolkit for our Toolkit, a one-stop shop for information, tools and resources to helpyou implement Heart Health Checks at your practice inthe simplest and most impactful way possible.
GP Events
Reproductive carrier screeningAdolescent contraceptionSyphilis and STI in pregnancyPost-partum contraceptionGestational diabetesUse of COCP in 2020Investigation of anaemia in pregnancy andmanagement
This WA Primary Health Alliance; HealthPathwaysWA GP education event is being delivered inpartnership with and presented by King EdwardMemorial Hospital. It will provide GPs with theopportunity to receive updated and evidence basedinformation regarding the care of young women whoshift between primary care and the specialist servicesat KEMH. Education sessions will include:
Date: Saturday 24 OctoberTime: 8:00am - 2:30pm
Accreditation:This activity has been approved for 18 CPD Activity(formerly Category 2 QI&CPD) points through RACGPand pending approval for 6 Educational Hours throughACRRM.
Registration and more information:https://www.wapha.org.au/event/real-women-real-care-managing-the-interface-between-primary-and-specialist-care-for-young-women/
R e a l w o m e n , r e a l c a r e :m a n a g i n g t h e i n t e r f a c eb e t w e e n p r i m a r y a n ds p e c i a l i s t c a r e f o r y o u n gw o m e n
View more upcoming GPeducation events atwapha.org.au/event
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08 6272 4900 | [email protected] | www.wapha.org.au
GP20 Virtual Conference RACGP OnlineNovember 6 - November 28
Does my Patient have a Drinking Problem?SIRCH ECUSaturday November 14
Updates in GastroenterologySt John of God MidlandTuesday October 20
GPs and practice nurses are invited to attend thelaunch of the Pilbara Health Professionals Network ata series of events throughout the region.
The network provides rural health professionals acentral hub that offers support and greateropportunities to network, upskill, share informationand collaborate in a local supportive communityenvironment.
NewmanDate: Thursday 22 OctoberTime: 6:00pm - 2:30pm
Karratha Date: Wednesday 28 OctoberTime: 6:00pm - 2:30pm
Port HedlandDate: Thursday 29 OctoberTime: 6:00pm - 2:30pm
Registration and more information : ruralhealthwest.eventsair.com/phpn/phpn-launch
P i l b a r a P r o f e s s i o n a l sH e a l t h N e t w o r k L a u n c h
The Death of a ColleagueRural Health WestOn demand
