Clinical Focus Wed, 12 Dec 2018 02:53:34 +0000 Joomla! - Open Source Content Management en-gb from the editor...

A heatwave across the country, and no sign of letting up. British politics also generating plenty of heat, both nationally and internationally.  

The NHS is rarely out of the news. A further two poisonings with Novichok, with one fatality. I am certain that without the dedicated expert care and high-quality NHS facilities, the outcomes would have been worse. Rightly the focus is on the methods of delivery of the poison and the perpetrators, but it would have been morale boosting if the medical services had more media time! The PM has indicated a further £20 billion for the NHS, welcome, but rapidly there was a realization it was not from the windfall figure painted on the side of the Brexit bus, but will require a rise in taxation levels. So much for windfalls.

Theresa May has been checked by her Chequers Brexit proposal but interestingly an amendment in the Commons did vote for continued collaboration and alignment of the Medicines Agency. It may not prevent the potential paucity of drugs in a “No Deal Brexit”, or other “Fudge” but at least UK will still benefit from the cooperation so vital in health of both medical devices and pharmaceutical products. 

GDPR, General Data Protection Regulations, came into force at the end of May and the world has not collapsed around us. Remember the Millennium bug worries. Nevertheless, to catch a few bad boys, Internet and Social media companies, every organization has been enmeshed in a net to capture a few. The cost to SMEs, including health organisations, is considerable, in both time and resources. More bureaucrats delivering a blunderbuss policy with an unproven evidence base. Generally, like drug lords, it already known who the main perpetrators are likely to be, so a focused approach would have been less costly.

The £20 billion mentioned earlier is hardly going to cope with the demographic changes which will result in an escalation of healthcare costs. One chronic disease, dementia, will be eating away large chunks of the health service cake. Devine (p.92) does not mention costs, that is a fact that all are aware of, but concentrates on the human and patient aspects. Gallagher and Hinchcliffe (p.74) highlight a common presentation in our ageing population.

Lord Hague, ex leader of the Conservative party and Foreign secretary, has added his weight to the debate on legalizing cannabis for recreational use. The debate was ignited by a mother demanding cannabis for her child, for medical purposes. Newton-Howes et al (p.84) provide a medical perspective of this much misunderstood drug.

Holidays will be in full flow by the time of publication of this issue and many of us will be reveling in the tropics. Try not to bring back unwanted skin souvenirs (Mounsey et al p.104). I was interested to learn that Intellectual Disability affects ~1% of the UK population, that is a whooping 650K (Sheehan et al p.113) and the vital role that GPs/Primary Care and Community physicians can play in managing patients who suffer. This issue ends with Fatty skin lumps (Bean et al p.124) focusing on investigations on the potential myriads of aetiologies and their radiological features.

Enjoy the summer and by the time of the next issue one of several events will have occurred. Boris Johnson may be Prime Minister, UK will have a no deal Brexit, a 2nd Brexit referendum will be called, an early election will be in the offing and the NHS will have a wonderful 70th birthday and will outlive all of us.

Professor Ram Dhillon


]]> (Editor Admin) Volume 12 Issue 2 - 2018 Fri, 27 Jul 2018 13:29:01 +0000
Identifying and managing acute confusion in older adults; beyond the hospital setting

Delirium represents a relatively uncommon, but important, presentation within primary care; particularly amongst at risk populations including those with dementia or living in residential care. Recognising delirium effectively is important to provide prompt and effective management to minimise adverse consequences.

]]> (Editor Admin) Volume 12 Issue 2 - 2018 Fri, 27 Jul 2018 13:49:15 +0000
Cannabis and the primary care physician

Cannabis, in herbal and synthetic forms, is becoming increasingly discussed in and advocated for the management of multiple health conditions. Some of this advocacy comes from both prominent figures and politicians. Alongside this there is significant work being undertaken to bring cannabis and products containing cannabinoids to market. This makes understanding the nature of cannabis, the biological and social pressures associated with its use and the evidence of treatment effectiveness, increasingly important. This paper provides a broad overview of cannabis and its potential uses in medicine.

]]> (Editor Admin) Volume 12 Issue 2 - 2018 Fri, 27 Jul 2018 14:00:37 +0000
Dementia: A Clinical Guide

Dementia is a common clinical syndrome affecting 1 in 14 adults over the age of 65 and a smaller number of younger people. This article explores presentation, assessment, differential diagnosis and management, providing an overview for the generalist and a more in depth insight for those with a special interest.

]]> (Editor Admin) Volume 12 Issue 2 - 2018 Fri, 27 Jul 2018 14:06:22 +0000
Unwanted Tropical Souvenirs

As global travel becomes more accessible, so is the incidence of diseases in the returning traveller. Secondary to gastrointestinal and fever of unknown origin, dermatological presentations are the most prevalent complaints with which patients present. Dermatoses can be non-infective, such as sunburn or worsening of eczema, or infective, and can be specific to the travelled area, such as Dengue or Zika, or can be also be found at home, such as cellulitis. Dermatological presentations are varied, and result in rashes, blisters, bullae, nodules or plaques, to name a few. This review aims to outline some of the most common conditions seen in the returning traveller; both those with primary and secondary dermatological manifestations, and how to manage them appropriately.

]]> (Editor Admin) Volume 12 Issue 2 - 2018 Fri, 27 Jul 2018 14:10:22 +0000
Intellectual disability – the essentials for General Practitoners

In this article we introduce the key features and health considerations associated with intellectual disability. Although roughly 1% of the population has an intellectual disability, their needs are frequently overlooked, both in medical training and in clinical practice. This contributes to worse clinical outcomes and excess mortality. General Practitioners have an important role in the co-ordination and delivery of high-quality care for this group.

]]> (Editor Admin) Volume 12 Issue 2 - 2018 Fri, 27 Jul 2018 14:17:19 +0000
‘Just a fatty lump?’- Imaging soft tissue tumours and suspected sarcoma

Soft tissue tumours, in particular lipoma, are relatively common with a very high cure rate and low rate of recurrence following excision. They outnumber malignant soft tissue lesions considerably, making identification of aggressive lesions difficult and potentially leading to diagnostic delays. Soft tissue sarcomas are a relatively uncommon group of malignancies arising in mesenchymal tissues, and hence, can occur almost anywhere in the body. In recent years, the investigation and management of these lesions have been centralised to a number of specialist centres throughout the UK in an effort to aid early identification and streamline management of malignant soft tissue tumours.

]]> (Editor Admin) Volume 12 Issue 2 - 2018 Fri, 27 Jul 2018 14:22:50 +0000
from the editor...

Early spring brought atrocious weather, The Beast from the East mingled with Storm Emma, putting pressure on public services across the board. It has illustrated again how much on the cusp such services are performing, particularly the NHS, as additional pressures could barely be accommodated.  

In the real-life drama that is associated with such pressures comes the case of Dr Bawa-Garba being convicted for manslaughter due to gross negligence, of the 6 year old child Jack Adcock. There has been a huge outcry as a single individual has been held responsible for what was clearly a systems failure. Dr Bawa-Garba was working as the sole paediatrician, responsible across three clinical areas, due to rota deficiencies. Additionally, her interaction with both a senior paediatric registrar and the consultant on call, resulted in no change in management being advised. Further disquiet has occurred as to the use of self-reflection documentation, which in this case was used against the doctor, as she had honestly indicated she could have done better.

Such is the concern at the court’s decision in this case that crowd funding has been instituted to pay for a formal appeal against the conviction. This is what natural justice demands but for the longer term more is required. It is required of politicians and our senior managers. Required to cease telling the public that all is well, stop the misinformation that more money is being poured in when it is mostly catch up or existing money, reallocated. No wonder, for the first time in decades, there are unfilled medical school places, which went to clearing, and up to 20% of foundation doctors are looking to emigrate! If this is coupled with the loss of our European colleagues due to Brexit, I see cases such as Dr Bawa-Garba’s, occurring more frequently.

This issue is packed with topics that confirms that Medicine is truly the “Noble Art” and that despite the current political and legal travails doctors, high ethics demands that they always do their best for patients. Successive governments have managed to undermine not just medicine but also primary dental care so Arora and Yeung provide a timely overview of the GP’s role in dentistry (p.6). The genome has been the rage for some years and Shantikumar and his colleagues’ contribution focuses on its value in primary care (p.14). Diabetes continues to be a major public health conundrum, whose prevalence is increasing despite all the efforts of government health initiatives. Hence, the complications of long term diabetes are going to be encountered more frequently by the GP and the article by Mohamedali and Gnudi, provides a neat resume of one such long term problem, diabetic nephropathy (p. 35). Parents worrying about growth issues in their children are frequent visitors to the doctor and Craig and colleagues give an insight on the sorts of issues the GP needs to be aware of and address (p. 47).

By the time this issue reaches you I hope the weather will be much improved and you are enjoying the shoots of a late appearance of the English springtime.

Professor Ram Dhillon


]]> (Editor Admin) Volume 12 Issue 1 - 2018 Wed, 14 Mar 2018 14:59:46 +0000
The role of general practitioners in recognising and managing dental disease

Oral health problems are extensive and multi-factorial in nature. Patient outcome will be compromised if there is limited access to trained dental professionals for oral health issues. The increasing number of dental patients going to the General Practitioners (GP) costs the NHS ‡26 million per year. The reasons why patients visit their GP for oral health issues are numerous; however, GPs are not responsible for treating dental patients. GPs do play an important role in identifying patients with undiagnosed dental problems, and being aware of the ones caused by other medical problems. Therefore, inter-professional cooperation is required to reduce the global burden of dental diseases.

]]> (Editor Admin) Volume 12 Issue 1 - 2018 Wed, 14 Mar 2018 15:33:39 +0000
Genomic medicine and primary care

Many diseases result from a combination of genetic, environmental and lifestyle factors. There is a huge amount of genetic variation between individuals, and genomics allows us to identify variations across whole genomes. Here we describe key concepts in genomics and discuss how it can be used to improve patient care.

]]> (Editor Admin) Volume 12 Issue 1 - 2018 Wed, 14 Mar 2018 16:38:06 +0000