August’s Medicine Today features three high-yield clinic pieces — HFpEF diagnosis, Sjögren disease beyond dryness, and vaccination as healthy ageing — with strong regular-series updates spanning dermatology, gastroenterology, ENT, paediatrics and dementia therapeutics.
Diagnosing HFpEF from suspicion to confirmation
Think HFpEF in unexplained exertional breathlessness or poor exercise tolerance, especially after 60 or with hypertension, obesity, diabetes or AF. A preserved EF (≥50%) is not enough on its own: pair the story with natriuretic peptides and objective congestion or raised filling pressures. Obesity can suppress natriuretic peptides, so a “normal” result does not rule out disease when suspicion stays high. Resting ECG, CXR and echo can miss early exertional disease; stress echo or right-heart catheterisation may be needed. Use H2FPEF or HFA-PEFF as aids, hunt mimics (anaemia, lung, thyroid/renal disease, ischaemia), and look for treatable phenotypes such as amyloidosis or HCM. Earlier recognition matters because SGLT2 inhibitors and contemporary therapies reduce symptoms and HF hospitalisation.
In clinic
- Do not dismiss breathlessness because EF is preserved or NT-proBNP is “normal” in obesity.
- Score with H2FPEF/HFA-PEFF, then chase confirmation and treatable phenotypes.
- Start comorbidity optimisation and consider SGLT2 inhibitors once HFpEF is established.
Sjögren disease beyond sicca
Dry eyes and mouth are common, but persistent sicca, parotid enlargement, unexplained caries or systemic clues should trigger a Sjögren work-up. Around 70% have extraglandular disease — ask about arthritis, lung or renal involvement, neuropathy, vasculitis and marked fatigue. Anti-Ro negativity does not exclude disease; objective ocular and salivary testing, and sometimes minor salivary-gland biopsy, still matter. Firm parotid swelling, lymphadenopathy or purpura needs lymphoma/vasculitis exclusion. Build a multidisciplinary plan from preservative-free lubricants and dental fluoride care upward, and arrange obstetric/rheumatology monitoring for pregnancy with anti-Ro/La antibodies.
In clinic
- Treat persistent firm parotid change or purpura as red flags, not “just dryness”.
- Remember seronegative Sjögren exists — use objective tests when the story fits.
Vaccination of older people
Vaccine-preventable illness drives hospitalisation, frailty and death in older adults. Opportunistically review shingles, influenza, RSV, COVID-19, pneumococcal, tetanus and pertussis against current Australian schedule/NIP advice. Shingrix is two doses; prefer high-dose or adjuvanted influenza where recommended. RSV is a single dose for eligible older adults, with particular attention at 75+ and Aboriginal and Torres Strait Islander people 60+. Keep COVID boosters current and tailor travel vaccines to itinerary and comorbidity. A clear clinician recommendation, reminders and attention to cost, transport and frailty lift uptake more than information alone.
In clinic
- Use every chronic-disease review as a vaccination audit in patients 65+.
- Offer RSV where eligible and keep Shingrix and influenza preference rules front of mind.
Highlighted regular series
Mohs micrographic surgery. Tissue-sparing, margin-controlled excision with high cure rates for selected nonmelanoma skin cancers. Refer recurrent, poorly defined or high-risk BCC/SCC on head, neck or genital sites; send diagrams, histology, prior treatment, anticoagulants/immunosuppressants and comorbidities. Expect a same-day staged process lasting several hours.
After GI bleeding — restarting antithrombotics. In many patients, restarting reduces thromboembolism and death despite higher rebleed risk. Original indication drives urgency (secondary prevention, AF, recent ACS/stent vs primary-prevention aspirin). Timing commonly sits around 3–7 days with specialist input; reconsider agent and combination rather than blindly restarting the same regimen. Prevent recurrence with NSAID avoidance, H. pylori testing/treatment and PPI gastroprotection where appropriate.
Paediatric ENT foreign bodies. Triage first for airway compromise, button batteries and magnets. Optimise the first removal attempt; for nasal objects, parent’s kiss can be useful. Avoid ear irrigation if the drum is uncertain or a battery is involved. Honey for button-battery ingestion is only a bridging option in children over 1 year within 12 hours, without delaying transfer.
Vaccine hesitancy. Separate ambivalence from firm refusal. Lead with empathy, invite concerns, give a clear recommendation, and use an ask–share–ask rhythm. For current decliners, protect trust and future access; make the practice convenient and use SKAI resources.
Lecanemab. Modest disease-modifying option for selected early Alzheimer disease with confirmed amyloid and APOE genotyping (ε4 homozygotes excluded in Australia). Expect fortnightly IV infusions for 18 months, MRI surveillance for ARIA, and substantial caregiver/specialist burden; not PBS-subsidised in this 2026 context. GPs identify candidates early, safety-net neurological symptoms, and help families weigh realistic benefit against cost and burden.
Clinician notes for personal CPD — not patient advice.
Article takeaways
Diagnosis of heart failure with preserved ejection fraction – from suspicion to confirmation
Pair clinical suspicion with peptides and objective filling-pressure evidence; obesity can falsely reassure on NT-proBNP.
Open article →Beyond sicca symptoms: diagnosis and management of Sjögren disease
Look past dryness for systemic disease; seronegativity does not exclude Sjögren when objective tests support it.
Open article →Vaccination of older people: an essential approach to maintaining wellbeing and quality of life
Treat vaccine review as routine healthy ageing — shingles, flu, RSV, COVID and pneumococcal all need opportunistic checks.
Open article →Mohs micrographic surgery: what to consider, when to refer
Refer high-risk or poorly defined head/neck/genital NMSC; routine lesions usually stay with standard excision.
Open article →After gastrointestinal bleeding: resuming anticoagulant and antiplatelet therapy
Restarting often saves lives; time restart to bleed severity and indication, and rethink agent/combination.
Open article →Paediatric foreign bodies in the ear, nose and throat
Batteries, magnets and airway risk go straight to hospital; make the first clinic removal attempt count.
Open article →Vaccine hesitancy – why it occurs and how to manage it
Empathy, a clear recommendation and ask–share–ask conversations beat labels; protect the relationship if vaccines are declined today.
Open article →Lecanemab – an amyloid-targeting therapy for early Alzheimer’s disease
Modest slowing of decline for carefully selected early AD; ARIA surveillance and treatment burden dominate counselling.
Open article →