Clinical Focus Tue, 14 Aug 2018 18:03:27 +0000 Joomla! - Open Source Content Management en-gb 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
Chronic Viral Hepatitis for the General Practitioner

Chronic viral hepatitis due to hepatitis B (HBV) and hepatitis C (HCV) is a global health concern with almost 500 million people infected and an estimated 1.46 million deaths per year. Many patients are asymptomatic and general practitioners should have a good working knowledge of risk factors and the appropriate tests to make a diagnosis, particularly as hepatitis B testing can be challenging to interpret. The natural history of disease is variable but both infections can lead to cirrhosis and hepatocellular carcinoma. The epidemiology and virology of HBV and HCV differ and their management can be complicated as there has been a huge increase in the number of drugs approved to treat both infections, particularly HCV, over the last few years. This article will provide a review of HBV and HCV for general practitioners who are often the first providers to encounter patients with viral hepatitis. A working knowledge of these conditions will permit a thorough work up and informed discussion with patients.

]]> (Editor Admin) Volume 12 Issue 1 - 2018 Wed, 14 Mar 2018 16:44:37 +0000
Diabetic nephropathy: an overview

Diabetic nephropathy is the major cause of end-stage renal disease. It is characterised by albuminuria and by a progressive relentless decline of the glomerular filtration rate. Current management with optimal blood glucose and blood pressure control prevents and slows disease progression as these factors contribute to disease pathophysiology. There are also new therapies currently being explored, which may have additional benefits.

]]> (Editor Admin) Volume 12 Issue 1 - 2018 Wed, 14 Mar 2018 16:58:08 +0000
Growth in Infants and Preschool Children

Concerns about a child’s growth are commonly encountered in primary care. These concerns may be raised by family members, healthcare colleagues or social care professionals. Steady normal weight gain is a commonly seen as a reassuring sign that an infant or child is healthy.

Abnormal growth has a wide range of possible aetiologies and is often multifactorial. A key role of the primary care practitioner is to consider the possibility of underlying systemic disease as well as review wider determinants of child health including socioeconomic situation, maternal mental health, parental and family behaviour and safeguarding issues.

Alongside faltering growth, considering what constitutes excessive growth is increasingly relevant in view of rising rates of childhood obesity and the long-term implications for the child and society.

This article presents an approach to assessing growth concerns. The identification of an abnormal pattern of growth should prompt a detailed assessment, management planning with families and sometimes referral for specialist care.

]]> (Editor Admin) Volume 12 Issue 1 - 2018 Wed, 14 Mar 2018 17:01:40 +0000
Principles & Practice of Postnatal Care

The puerperium marks the 6-8 week post-partum period, where the body reverts back to its pre-pregnancy state with the resolution of the anatomical, physiological, endocrine and biochemical changes of pregnancy. Effective postnatal care should include provision of support with regard to breast feeding, emotional wellbeing and management of birth -related complications such as perineal tears, and, advice regarding contraception. Timely recognition and management of complications, which may occur during the postnatal period such as secondary haemorrhage, endometritis, wound infections, venous thrombo-embolism and post-partum psychosis is vital to optimise maternal and neonatal outcomes.

]]> (Editor Admin) Volume 12 Issue 1 - 2018 Wed, 14 Mar 2018 17:12:55 +0000
from the editor...

It has been an odd summer, and autumn has already and will usher in further calamities. On the home front, the Brexit debate has moved from the extreme hardline exit to a softer approach now that that the consequences of the simple IN or OUT vote have been gradually unveiled by a much-divided government and a slightly less divided opposition. I note a that May et al have subtly indicated changes in their stance, with a wish to continue membership of Research organisations (UK has awards of ~ 1 billion Euros per annum from the EU), Security organisations, there has been a shift on immigration………the list goes on. Strangely, as far as the NHS is concerned, NHS England are looking to attract 1000s of doctors, from the EU, to fill the deficit in GPs! I am not entirely certain they will be able to fulfil the need, as EU healthcare professionals are leaving the UK, rather than flocking to it. We shall probably have to turn to the Commonwealth, India, Australia, Canada….to fill the gaps left and additionally to make up deficits from poor workforce planning.  

Recently, there have been headlines not just on the increasing problem of drug resistance microbes, due to injudicious use of antibiotics, but an interesting volte face on the absolute need to finish a course of antibiotics. The new mantra is to stop as soon as symptoms improve. Nayar and Li Chin provide an overview of the problem of multi-drug resistance, focusing Enterobacteriaceae (p154).

Growing old is not much fun. Aches and pains and worse slowly but surely will prevail. For middle and late aged females, there is the potential problem of the male LUTS, named FLUTS (Female Lower Urinary Tract Symptoms). These group symptoms are unpleasant and can be socially debilitating. All GPs will have a number, which will increase due to the ageing demographic, on their lists. Kumar et al provide an excellent contribution to assist you in managing this increasingly common problem (p158).

Chronic diseases are a significant workload, with hypertension being one of many. Hypertension may herald medical consequences of a severe nature so must be taken seriously to avoid not just personal tragedy but the economic
costs of complications. Patel et al have neatly encapsulated the role of the community physician in managing this all too prevalent silent harbinger of death and destruction. Tracy and Shridar address the issue of Novel Psychoactive
Substances (legal highs), which are not legal! Primary Care has an important role in identification of use and in managing the medical and social consequences of their use (p174).

Increasing numbers of patients wish to die at home and not in hospital or care homes. GPs will need to have the knowledge and skills to manage some of the distressing symptoms that individuals will experience. Al-Qurainy et al have focused on the key areas of concern for patients requiring palliation and how they may be addressed, by illustrating through patient scenarios (p183).

We have introduced a Clinical Vignettes section, which it is hoped will bring a little light relief from the more extensive medical pieces.

Please drop me a letter with any comments, ideas and suggestions.

Professor Ram Dhillon


]]> (Editor Admin) Volume 11 Issue 3 - 2017 Mon, 19 Feb 2018 13:46:20 +0000
The Problem of Multi-Drug Resistance in Enterobacteriaceae

Increasing levels of antimicrobial resistance are currently a big problem in the management of Gram negative infections caused by enterobacteriaceae. This article reviews resistance mechanisms, focusing on a management approach relevant to primary care.

]]> (Editor Admin) Volume 11 Issue 3 - 2017 Mon, 19 Feb 2018 14:51:13 +0000
Management of Female Lower Urinary tract Symptoms in primary care

The Female lower urinary tract symptoms (FLUTS) are a collection of symptoms akin to the wellknown lower urinary tract symptoms (LUTS) in male counterparts. It is a common presentation in primary care consultations, particularly in women of middle to late age. Awareness of risk factors and actively looking out for these cases may be worthwhile particularly as patients may not be very forthcoming with this problem. Careful history taking, examination and assessment of its impact on quality of life (QOL) are of paramount importance. There is a need to carry out holistic assessment of these patients prior to offering management plan, which can include self-help measures, behavioural treatment, medications and surgical treatment.

This article illustrates the magnitude of the problem and will assist clinicians in primary care to identify, diagnose and manage patients with FLUTS in an evidence-based manner.

]]> (Editor Admin) Volume 11 Issue 3 - 2017 Mon, 19 Feb 2018 15:14:56 +0000