The overuse of diagnostic testing in primary care, particularly for nutrients such as folic acid, vitamin B12, and zinc, is a prevalent issue driven by a 'better safe than sorry' mindset and an emphasis on preventive medicine. This article reviews the evidence against routine broad-spectrum testing in the absence of clear clinical indications, highlighting studies that demonstrate the unnecessary nature of such tests in patients without specific risk factors. The Royal College of Pathologists and the Choosing Wisely initiative recommend against indiscriminate testing, as it may lead to a cascade of further unnecessary interventions, increased healthcare costs, and heightened patient anxiety. This paper proposes targeted initiatives to rationalize testing practices, including the implementation of clinical decision support tools, enhanced education on high-value care, regular audit and feedback mechanisms, and improved continuity of care by linking test ordering with follow-up responsibilities. By adopting a more evidence-based approach to diagnostic testing, we aim to minimize unnecessary interventions, reduce healthcare expenditures, and ultimately enhance the quality of care provided to patients.

Background: Actinomycosis is a rare, chronic granulomatous infection caused by Actinomyces species, often affecting the cervicofacial region, particularly the submandibular gland.Case Presentation: We report a unique case of actinomycosis in a 69-year-old woman with a history of recurrent sialolithiasis. The patient presented with swelling, tenderness, and discharge from the submandibular region. Despite prior surgical interventions and antibiotic treatments, symptoms persisted, leading to a thorough evaluation. Imaging studies indicated significant sialolithiasis. A biopsy of the affected gland revealed actinomycotic granulomas, confirming the diagnosis.Management: The patient was treated with prolonged high-dose penicillin therapy and underwent surgical resection of the affected gland.Conclusion: This case underscores the importance of considering actinomycosis in differential diagnoses of chronic submandibular infections, especially in patients with recurrent sialolithiasis. Early recognition and appropriate management, including long-term antibiotic therapy and surgical intervention, are crucial for effective treatment.

This critical analysis evaluates the clinical practice of zinc testing in patients presenting with asthenia, based on an observational audit using the EMIS Primary Care System, involving 48 patients from a population of 46,755 individuals. The study investigates gender-based differences in zinc levels and assesses whether low or borderline zinc levels correlate with asthenia. Results indicate that females are more likely to exhibit borderline low zinc levels. However, no definitive relationship between zinc deficiency and asthenia was observed. This suggests that attributing fatigue to marginal zinc levels may lead to over-diagnosis, particularly in females. Misinterpreting non-pathological zinc values could contribute to patient anxiety and diminished trust in healthcare.Key Words: Zinc, Asthenia, Zinc Deficiency, Gender Differences, Subclinical Deficiency, Over-diagnosis, Trace Elements, Nutritional Deficiency, Fatigue, Clinical Audit

A document by Edoardo Cervoni. Click on the document to view its contents.

The human body is, by definition, a "corpus". This Latin term emphasises the synergy and interdependence of each of its parts. There is no scientific basis for estimating the number of specialists of various types needed to meet the population's needs of the type of interventions that confer benefit. However, it is virtually certain that the proper functioning of the filter could free up more time for properly deployed specialists to provide services that would significantly improve health and, above all, equity in health.  Recognition of the importance of first contact function in Primary Care as a filter and co-ordinator, should lead us to better clinical outcomes for the most part. The government should recognise, protect, and prioritise, the role of the Primary Care interface. 

Far more intense efforts are needed to identify the characteristics of the long COVID before nourishing the ambition of being able to address the problem effectively. Syndromes are, by definition, heterogeneous and difficult to manage in the absence of a clear understanding of the causal mechanisms. The plethora of symptoms affecting multiple systems exhibited by "long COVID sufferers" suggests several underlying mechanisms1,2,3. In this sense, long COVID is a syndrome par excellence. Being a heterogeneous condition from a pathophysiological point of view requires efforts to improve its understanding, diagnostic accuracy and, above all, establish an effective therapeutic program. The latter cannot be achieved ahead of the antecedent two steps. The National Institute for Health and Care Excellence (NICE), the Scottish Intercollegiate Guidelines Network and the Royal College of General Practitioners have developed a quick guideline for managing the long-term effects of Covid-19. The current guideline lacks essential details, including a comprehensive list of organ complications seen in patients with long COVID, the required investigations, and specific interventions for these complications4,5. It is not clear which speciality could be more suitable for aggregating patients suffering from long COVID. Preliminary to initial referral mandatory exams include FBC, U&E, LFTs, CRP, CK, haematinics, TSH, HbA1c, Calcium, BNP, ECG, CXR, SpO2, RR, HR and temperature. The lack of a specific target underlines the generality of the approach. It leaves us with doubts about what the clinics responsible for managing long COVID are expected to do, at least in the hospital setting. Furthermore, we are moving from the premises of a diagnosis of exclusion. It is even not clear what the overall cost of the initial referral is. Costing should include the charges for the multitude of mandatory tests - often already recently performed, but not within the six weeks antecedent to the referral as per requirement - plus the first hospital consultation charge to the NHS. It also remains to be established what the referring doctor and the patient should expect from the referral, especially in the treatment plan. A cost-benefit analysis – that is, the process used to measure the benefits minus the costs associated - of the long COVID clinics in their current form appears to be lacking. Such analysis should also factor in the opportunity cost in the decision-making process. Opportunity costs are alternative benefits deriving from choosing one alternative over another. In other words, the opportunity cost is the forgone or missed opportunity because of a choice or decision.  The above situation, once again, emphasizes the need for at least more solid diagnostic and pathophysiological premises before proceeding further with clinics and therapeutic programs, other than in a field of scientific research aimed at obtaining more information. In the absence of measures so designed, the long COVID can produce a second crisis of the health system and the job sector in the wake of the pandemic itself. Until we have a better idea of dealing effectively with long COVID, there is a strong case for redirecting any money destined to the Long COVID Clinics to clinical research on long COVID and Primary Care. A golden rule in healthcare is that spending more on prevention, early detection, and better-diagnosing spares patients suffering and leads to less complex and less expensive care later.

After the pandemic extent of SARS-CoV-2 infection was recognized in mid-February 2020, indicators of influenza activity began to decline worldwide.The significant reduction in influenza activity may have implications in terms of forecasting the most appropriate strains towards which to direct the 2021/2022 vaccination campaign, its possible benefits against the inevitable costs, not only economic, but also organizational. The latter deserve special attention by virtue of the realistic need for a new mass vaccination for Covid19 in autumn 2021.In order to have a better perception of the fluctuation of influenza activity at the level of General Practice, we verified the cases of influenza diagnosed after hospitalisation for pneumonia and flu-like illness for a period of 5 years in a population belonging to a large GP Surgery in Merseyside, UK.

The presence of pigmented and partially pigmented skin lesions of non-univocal interpretation should always trigger a cautious approach. Albeit the diagnosis of malignant melanoma should remain our main concern, other more common skin conditions, namely basal cells carcinoma, should be taken into consideration in the diagnostic process and management plan. The following case highlights how, sometimes, the diagnosis of partially pigmented basal cells carcinoma may not appear to be immediately evident and the opportunity to deal with non-surgical approach missed. Case report 50-year-old man of Caucasian origin, phototype III in Fitzpatrick scale, initially presenting with a 6-month history of pigmented, inflamed, flat skin lesion at the base of the neck. The lesion had been noticed in the summer months due to the itching and occasional burning it caused (figure 1). Physical examination revealed a 7 mm x 8 mm superficial skin lesion, partially pigmented, not well defined, slightly hyperkeratotic, against a background with several lentigo and nevi. No particular concerns were raised by dermoscopy, or dermatoscopy, and the patient was reassured, even though a small white clod was noted.

INTRODUCTION: PD is more common with increasing age and shows male predominance, which is more obvious in Western studies. The reasons of this remain obscure. However, it has been suggested that exposure to endogenous and exogenous oestrogen contributes to these sex differences and that oestrogen prevents dopaminergic neuron depletion induced by neurotoxins in and therefore is neuroprotective. OBJECTIVES: we wanted to investigate if the exogenous administration of testosterone in males, and oestrogen with or without progesterone in females, had any protective effect towards to PD. METHODS: clinical records of 99929 residents in North West England were scrutinised in primary care setting for diagnosis of PD, HRT, and timing of onset in those cases were the adverse event had been identified.RESULTS: PD overall prevalence was of 0.55% in males and 0.36% in females (M/F=3:2). The NNT for HRT with testosterone was 1.016 (harm) significance level P<0.0001, and NNT for HRT oestrogen+/-progesterone was 17.092 (harm) significance level P<0.0001.CONCLUSIONS: HRT for males or females have not demonstrated any beneficial effects in terms of PD onset prevention or procrastination. On the contrary HRT, particularly with testosterone, is more likely to have a detrimental effect. Our results need to be interpreted cautiously as the treatment with HRT was not randomized and it cannot be excluded that stopping HRT may cause a sudden hormonal drop which in turn may have a negative effect.

Introduction In different Countries and different Healthcare Systems, GP workload is significantly burdened by a minority of patients seeing their GP a lot more often than their peers (1).Those are patients are generally well-known to their family physician as subjects that make the ”heart sink” and therefore were initially called by O’Dowd “heartsink patients” (2).But when, more precisely, a patient “becomes” a high user or frequent attender ”?Even if the phenomenon is not new, we do not have data to define quantitatively this “entity” and we ignore if the prevalence of FAs as increased over time, or if it hasn’t (3,4).We do not have precise data about the average duration of their GP encounters, which could well differ from the standards 10 minutes, hence likewise affecting the burden on GP time.To describe those patients, we still often reference to a work published in 1988. It is believed that Tom O’Dowd then coined the term ”heartsink”, to describe ”The feeling experienced (by the family doctor) when their names (of patients) appear in the list of the morning appointments. ” (1)Further work has been done to define the reasons behind the frequent GP visits. In 1988, O’Dowd acknowledged that the medical experience was subjective, but perceived that the problem and its solution resided both in the patient.A systematic review from Gill and Sharpe on prevalence, associations and clinical outcomes, and subsequent observations from other Authors, have shown that FAs have high rates of physical illnesses, psychiatric illnesses, social difficulties and emotional distress (3,5).Frequent attendance in General Practice is also considered an indicator of behaviour of inappropriate use of other health services, in particular emergency departments and Secondary Care services (6,7,8).Evidence of the effect of (mainly psychiatric) interventions on the rate of frequency and morbidity ofFAs have shown conflicting results (9,10). In a review of the interventions on FAs, it was found thatthe high frequency can be a sign of a major depressive disorder and that its treatment can improve the depressive symptoms, but there is no evidence that it is thereby possible to influence the use of the services (11).The interpretation of the studies on FAs is hampered by differences in Healthcare Systems and in the definition of FA (12).It has been shown that age and sex are highly associated to the number of GP visits and that the identification of FAs without adjustment by age and sex leads predominantly to the selection of older women (13).After reviewing the literature on high users, Vedsted suggested that the FA should be described as a subject that falls at the top 10% of the practice population stratified by age and gender (4).Vedsted, suggested to arbitrarily fix a threshold in the distribution of the frequency of consultation, such that they are considered FAs all those who go above the percentage or percentile set as threshold.However, this choice is associated with various problems of practicality with one key disadvantage that is of failing to identify a number of variabilities in relation Health Care System, for instances.In this work, we checked the frequency GP encounters, both in office and at patient’s domicile, over the course of 12 months, in both sexes, and in all age bands.We then looked at the number of visits over the course of a year above which such number increases rapidly, isolating a limited group of patients to whom was associated an extremely high number of GP encounters.Doing so, we aimed to clarify if and where the proportional threshold value and the absolute threshold value may converge.We believe that they do converge and that this number can be identified as the most useful threshold value for the definition FA.MethodIn the context of a General Practice medium density urban setting, we collected data on 9651 people registered with 4 different GPs.Unlike most previous studies on FAs, we have not ruled out children and the most elderly.In fact, several studies have only used data from patients aged 15 to 74 years.For all patients registered during the 12 months prior to the audit date, we only counted the GP face to face consultations, either at the Surgery or at home of the patient. We have calculated the contact frequencies of all patients for each combination of age and gender. The top 5% of patients in terms of frequency of yearly encounters has been defined using the concept of proportional threshold.ResultsThe characteristics of the population studied is graphically represented in figure 1, they are the following:Mother population: Patients currently registeredLast Search: 01-mar-2018Relative Date: 01-Mar-2018Population count: 9651Males: 4540Females: 5111

Both acute otitis media (AOM) and tonsillitis are common presenting complaints in Primary Care and ENT setting. Tonsillitis accounts for between 5 and 10% of all cases of illness seen by the general practitioner. This has been a rather stable prevalence over the last 100 years or so (Collins, 1935). The analysis of the incidence by age shows, for both tonsillitis and sore throat, a relatively high incidence in childhood and young adults, while after that period there is a fall with age. Laryngitis, on the other hand, appears to occur more frequently among adults than among children. The incidence of tonsillitis, sore throat and other pharynx diseases is higher among females than males. There is no indication among school-age children that there is a higher incidence in women. There is a fairly regular seasonal variation in incidence as well, with higher incidence in winter and spring.Acute otitis media appears to be far more prevalent in children under the age of 10 and significantly less common from the third decade of live onwards. The UK was put into lockdown on 23 March 2020 in an unprecedented step to attempt to limit the spread of coronavirus. From an audit of over a total population of 9534 people, starting from the beginning of the lockdown to the 18 May 2020, the number of patients with diagnosis of tonsillitis was audited. The data were compared to those recorded in the 5 precedent five years during the very same period of time. Tonsillitis accounted, on average, for 8% of all cases of illness seen by the general practitioner from 2015 to 2019. The mean number of patients seen for tonsillitis was 805.8 with SD of 28.96. In 2020, the number of cases of tonsillitis was 593. From 2015 to 2020, the higher incidence in the female sex was confirmed from all the age bands>19. The greatest drop in cases was not recorded in the age group 0 to 9, but - in the order - 10 to 19, 20 to 29 and 30 to 39 with a reduction above the 30% in the first 2 age bands. Overall, the drop was seen across all the age bands (Cervoni, 2020).The same cannot be said for the diagnosis of acute otitis media in its various forms. To establish the impact of the lock-down on the diagnosis of acute otitis media, we audited a total population of 9534 people, starting from the beginning of the lock-down in March 2020, to the end of the phase 1 of the lock-down in May 2020, for the number of patients with diagnosis of AOM.  From 2015 to 2020, across the very same period of time, there has been a relatively stable prevalence with, perhaps, a slightly decreasing trend.The drop recorded during the pandemic does not reach statistical significance.Furthermore, differently from the diagnosis of tonsillitis, there is not obvious difference of incidence between males and females.  

Tonsillitis accounts for between 5 and 10% of all cases of illness seen by the general practitioner. This has been a rather stable prevalence over the last 100 years or so. The analysis of the incidence by age shows, for both tonsillitis and sore throat, a relatively high incidence in childhood and young adults, while after that period there is a fall with age. Laryngitis, on the other hand, appears to occur more frequently among adults than among children. The incidence of tonsillitis, sore throat and other pharynx diseases is higher among females than males. There is no indication among school-age children that there is a higher incidence in women. There is a fairly regular seasonal variation in incidence as well, with higher incidence in winter and spring. The UK was put into lockdown on 23 March 2020 in an unprecedented step to attempt to limit the spread of coronavirus. From an audit of over a total population of 9534 people, starting from the beginning of the lockdown to the 18 May 2020, the number of patients with diagnosis of tonsillitis was audited. The data were compared to those recorded in the 5 precedent five years during the very same period of time. Tonsillitis accounted, on average, for 8% of all cases of illness seen by the general practitioner from 2015 to 2019. The mean number of patients seen for tonsillitis was 805.8 with SD of 28.96. In 2020, the number of cases of tonsillitis was 593. From 2015 to 2020, the higher incidence in the female sex was confirmed from all the age bands>19.  The greatest drop in cases was not recorded in the age group 0 to 9, but - in the order - 10 to 19, 20 to 29 and 30 to 39 with a reduction above the 30% in the first 2 age bands. Overall, the drop was seen across all the age bands.