Clinical Focus Fri, 23 Feb 2018 22:14:16 +0000 Joomla! - Open Source Content Management en-gb from the editor...

The deed is done. Brexit is happening. We shall see what it brings to the NHS, a worsening of frontline medical and non-medical staff by all accounts. A trickle of exits of EU citizens may turn to a deluge if the issue of retaining citizenship is not resolved, early on in the negotiations. The worry is that the UK government may be relying on recruiting from outside the EU, such traditional heartlands as India, Nigeria and other Commonwealth of Nations. I am not sure if this will be easy as the laws on immigration and rights have so parred the advantages that there is unlikely to be a rush of healthcare staff wishing to come to the UK. The double whammy for politicians is that increasing numbers of staff, particularly in primary care, are choosing to retire early, work part time or simply have a career change. Plugging this gap, with the decision for additional places in medical school, will take over a decade for the effect to show. Indeed, the last round of undergraduate medical school places were unfilled and had to be offered in clearing. I cannot remember this happening in my working lifetime, 39 years. Jam tomorrow then!  

Cynicism is rife with most of the government initiatives. STPs, for example, are designed to make the health service more efficient, provide better care and rationalise services. For many it is a euphemism for saving money and cutting costs i.e. reducing services. The government still has not explained where the resource for implementing STPs, worthy they may be, will be coming from. No new money is forthcoming, so the assumption is it will be generated by internal service reduction, as efficiency savings have now gnawed on the bones of the NHS. No waste left to trim. All this may be irrelevant as we could be in the midst of a nuclear war as one testosterone man, Donald Trump, confronts his doppelganger alpha male, Kim Jong-Un, in a demonstration of, “anything you can do I can do better”. Mind you Trump does so many U turns that he is positively spinning i.e. Obamacare, Mexican Wall, Obsolete NATO……….so maybe he will resist the urge to teach the Korean leader a lesson.

The world keeps turning and people keep falling ill despite the games played by politicians. Healthcare staff, who have little control over most events, can still provide comfort and hope to those with illness. This may have huge non-monetary benefits to the healthcare giver. The death of Emma Morano, who, until earlier this year, was the oldest living person, aged 117, prompted a search for the factors in longevity. One I came across was that selflessness is key to a long life. For Morano it must have been ultruism and the 2 raw eggs eaten each day for the previous 90 years.

This issue has a piece on Colorectal cancer (p.74, Thrumurthy et al) and an interesting resume on Poisoning, and the role of primary care (p.89 by Fok et al). We hear a lot about mental health in adults, but little about children suffering the same. Burden, p.101, redresses this imbalance with a focus on Depression in children and adolescents. GPs must see many patients with possible hip symptoms. Ranjit et al, p.110, have provided a useful “What you need to know”, overview. Perianal dermatoses, p.121, by Abu-Asi et al, is not glamorous, but highlights an important clinical area, where diagnoses can be made readily in the community and the patient managed, therefore, appropriately. Finally, Han et al, p.138, have put together a succinct and pictorial piece on Red flags in eye disease.

Do remember that for your appraisal and revalidation, verifiable CPD activity is available on line for each of the contributions, which permits you to assess your knowledge base and skills.

Please email comments and suggestions to me.

Professor Ram Dhillon


]]> (Editor Admin) Volume 11 Issue 2 - 2017 Fri, 28 Apr 2017 07:47:43 +0000
The diagnosis and management of colorectal cancer

Colorectal cancer is the third most common cancer in men and the second most common cancer in women worldwide. Incidence strongly increases with age, with the median age at diagnosis being 70 years in developed regions. Although 5-year relative survival exceeds 90% in stage I disease, it only marginally exceeds 10% in stage IV disease. This review aims to guide generalists through the early diagnosis, referral, and treatment of colorectal cancer, and highlight current preventive strategies.

]]> (Editor Admin) Volume 11 Issue 2 - 2017 Fri, 28 Apr 2017 08:12:58 +0000
Poisoning: an update for primary care professionals

Primary care professionals are amongst the most frequent users of the National Poisons Information Service in the United Kingdom. This paper provides an up-to-date review on the management of acute poisoning in this setting.

]]> (Editor Admin) Volume 11 Issue 2 - 2017 Fri, 28 Apr 2017 08:42:05 +0000
Depression in children and adolescents

Depression is a common mental health disorder in children and adolescents and presents relatively frequently to primary care. Early recognition, assessment and treatment of depression is important to alleviate distress, improve functioning and later outcome, and manage risks. Primary care and tier 1 professionals may manage mild depression whilst moderate to severe depression is usually managed by specialist mental health services. Treatment of depression is dependent on severity and individual circumstances; interventions include supportive measures, addressing stressors, psychological therapy, and antidepressant edication in selected cases.

]]> (Editor Admin) Volume 11 Issue 2 - 2017 Fri, 28 Apr 2017 08:54:13 +0000
Hip Disorders: When to worry

Hip pain is a common presentation in GP practices across the country. It can be caused by a multitude of different pathologies ranging from simple muscle spasms, to fractures. It is vital that health professionals can differentiate between benign causes, which can be treated in the community setting, to symptoms that warrant specialist input.

]]> (Editor Admin) Volume 11 Issue 2 - 2017 Fri, 28 Apr 2017 08:58:17 +0000
Perianal Dermatoses: a clinical approach to management

Perianal dermatoses and pruritus ani are common and socially embarrassing conditions that are often poorly managed. Perianal dermatoses encompass a variety of inflammatory diseases affecting the anal region, of which eczema, of various aetiologies, is the most common. 

Pruritus ani is a chronic itch of perianal skin without rash and is poorly understood. There is a knowledge gap in understanding the pathophysiology and management of pruritus ani as there has been little research. 

The aim of this article is to present an overview of perianal dermatoses and their management.

]]> (Editor Admin) Volume 11 Issue 2 - 2017 Fri, 28 Apr 2017 09:00:42 +0000
Red Flags in Ophthalmology

Eye problems account for 4.5 million GP consultations yearly, in the United Kingdom, and evidence shows that 50% of sight loss could be avoided through improved eye care and early detection. While often it is obvious when an eye condition needs referral (for example the red, painful eye, or sudden loss of vision), there are a number of potentially blinding or even lifethreatening conditions which may present atypically or with subtle signs that may be missed. Such misdiagnoses can have serious implications. 

This article examines common presentations in ophthalmology and suggest some important ‘red flags’ in each which merit urgent attention. We have placed emphasis on conditions which can be life or sight-threatening, which can present atypically, and whose ‘red flags’ are aspects of history or examination which are easily and quickly elicited in the GP consultation. 

It is worth noting that while many of the conditions discussed frequently present with eye symptoms (and indeed may be seen in eye casualty), they may in fact reflect other underlying disease processes (e.g. raised intracranial pressure). Having the conviction to refer such patients directly to the medical or neurology team for treatment results in a safer and faster patient journey.

]]> (Editor Admin) Volume 11 Issue 2 - 2017 Fri, 28 Apr 2017 09:04:27 +0000
from the editor...

We shall be through a month or so of 2017 by the time this issue is published. Donald Trump will have been inaugurated. The Supreme Court in UK will probably have decided as to whether Parliamentary consent is required to trigger Article 50 for Britain’s exit from the EU…………………The runes are not good reading.  

Trump is likely to ditch Obamacare which was designed to make healthcare an affordable reality for those that are not wealthy. It has been much maligned by the private sector corporations who clearly see it as a mechanism for reducing their profits. In the UK, if the Supreme court decision rules in favour of Gina Miller, the plaintiff who challenged the notion that the government did not require parliamentary approval, then a short-lived sigh of relief will be heard from the approximately 25% of the NHS, who make the EU component of its workforce. This will not avert the crisis of unfilled GP posts,, the haemorrhage of doctors leaving for life and careers abroad (Australia, New Zealand, Canada…..). Jeremey Hunt’s increase in medical student numbers will not catch up for over 15years, assuming Medicine is a choice that teenagers will make. Unlikely, as this last round of University entry, as never before, had medical school places available in clearance. Hunt has managed a first at least.

Prime Minister May gave an early 2017 interview on Sky which appeared to lead to a sharp drop in the value of the pound. Sir Ivan Rogers, the EU Ambassador has resigned, maybe he was pushed, as he issued a properly prepared civil service reality check, stating that Britain’s plan for Brexit was a muddle and trade negotiations may take 10 years!! Whistleblowers and the messengers are treated with equal disdain in politics and the NHS. Theresa
May has provided some soundbites. She has substituted Cameron’s “Big Society”, with the “Shared Society”. It has the identical wooliness that came with the meaningless phrase “Brexit Means Brexit”. She did provide a little hope by promising additional support, including money for Mental Health. As a cynic I suspect this is playing to the gallery, particularly the £15 million mental health fund i.e. organisations must compete for it, presumably because there is not enough cash allocated. I rest my case.

At least let us get back to reality with the papers in this issue. The prevalence of depression is such that £290m was the NHS spend in 2015 on antidepressants. There is increasing evidence of their potential harmful effects, which have been neatly highlighted by Schlezak & Kripalani (p6). Febrile seizures are a terrifying experience for any parent, with the worry of potential permanent cerebral damage to the child. Newton and Cotton provide a timely contribution on how to manage the acute phase and a proforma on how to address the issues that will be raised by parents and carers (p16).

This issue tackles two chronic diseases. One poorly understood and rarely makes the headlines, Occupational Asthma (OA) by Feary and Cullinan (p23) and Diabetes, which is hardly out of the news headlines or health sections. The inability to recognize and manage OA can blight careers and health and accounts for about 15% of new asthmas diagnosed in adulthood. The inexorable rise in diabetes may well bankrupt the NHS unless major steps are taken to prevent its development and better manage it when diagnosed. The article by Prashanth (p35) focuses on diabetic neuropathies, which once established are not reversible but need to be identified early and managed to prevent even worse chronic debilitating effects.

Finally, the juxtaposition of a pregnant woman being treated with antiepileptic drugs (AED) is addressed succinctly by Kinney and Morrow(p49). The role of the GP is a key element in managing those in confinement at a time when they feel vulnerable and with the burden of knowing that AEDs can cause congenital foetal abnormalities.

A true mixed bag of medical issues which should keep the readers well engrossed in the cold winter months. The next issue will cover aspects of colonic cancer, revisit depression but this time concentrating on the younger ages groups (children and adolescents), a tour around the red eye and much more………..

Do remember that for your appraisal and revalidation you could do a lot worse than attempt the CPD activity available on line for each of the contributions that will permit you to assess your knowledge base and skills.

Please email comments and suggestions to me.

Professor Ram Dhillon


]]> (Editor Admin) Volume 11 Issue 1 - 2017 Wed, 25 Jan 2017 09:02:36 +0000
Can antidepressants be harmful?

The quality of prescribing would benefit patients and GPs as antidepressant prescriptions have doubled to 61 million in the last 10 years. The “net ingredients cost” (NIC) of drugs to treat depression was £284.7 million in 2015., the Health and Social Care Information Centre (HSCIC) figures show.

We would all like to promote evidence based treatments and hence aim to disregard emotive rhetoric as we move forward in to the realm of seamless care between physical and mental health. During our attempt below, we touched on specific advice in certain the age groups, though we recommend specialist advice for all groups. We did not discuss precautions needed for special patient groups, which may require antidepressant medication (e.g. poststroke depression, depression with psychotic features, somatisation/hypochondriasis, acute or enduring mental health presentations etc.) as we believe such complex categories would require specialist attention.

Recent literature demonstrates the reduction in suicide attempts following introduction of an antidepressant and the rates are statistically lower, than in untreated depression. This is a welcome addition to the discussions we have with our patients and their families. In this article we looked at the most common classes of antidepressants, their interactions and side effects, onset of action timeline, swapping and stopping, suicidality and prescribing in other age groups such as the young and the elderly. We recommend specialist advice and input when unsure of the best way forward.

]]> (Editor Admin) Volume 11 Issue 1 - 2017 Wed, 25 Jan 2017 09:06:39 +0000
Febrile Seizures

Febrile seizures affect about one in 30 pre-school children. The peak incidence is at 18 months and they are most common between the ages of 6 months and 6 years. Causation is probably multifactorial with environmental factors and genetic factors playing a part. The immaturity of both the immune system and brain probably contribute to the phenomenon. Most febrile seizures are generalised tonic-clonic seizures, and about 30-35% have one or more complex features (focal onset, duration >10 minutes, or multiple seizures during one illness episode). Complex seizures augment both recurrence risk and the chance of developing a future epilepsy. Rarely, recurrent febrile seizures may point to a family with genetic susceptibility genes (eg GEFS+) often involving mutations in sodium channel genes, important for neurotransmission. Most children with febrile seizures do not require hospital admission. Clinical assessment should include scrutiny of risk factors for central nervous system infection.

The mainstay of management in the acute stage is first-aid management of the airway, calming the situation and subsequently offering the family information. If they understand more it will add to their confidence in managing a possibly recurrence. An approach is suggested here on how a simple biological model might be used to aid understanding. There is no evidence-base to support the use of either prophylactic antipyretic or antiepileptic drugs to reduce recurrence risk. Rescue treatment in the form of buccal midazolam or rectal diazepam should be prescribed for those with a high recurrence risk. Rescue treatment should be used if the motor component of the seizure is lasting longer than 5 minutes or if the time of seizure onset is not known.

Parents should be reassured that having a single simple febrile seizure does not pose a threat to a child’s cognitive development. Recurrent seizures may be associated with language or memory impairment but there is no association with behaviour disorder or cognition. These risks can be discussed in an encouraging context as early identification can lead to the provision of early intervention and support, saving distress for the child.

]]> (Editor Admin) Volume 11 Issue 1 - 2017 Wed, 25 Jan 2017 09:11:03 +0000