InnovAiT - recent issues

News & Views

Etherington, C., van Hecke, O. — Tue, 17 Nov 2009 06:53:10 PST

Hypercalcaemia

Waters, M. — Tue, 17 Nov 2009 06:53:10 PST

Hypercalcaemia has an incidence of approximately 1 in 500 in the community. It is most commonly caused by malignancy or hyperparathyroidism (90% of cases). Severe hypercalcaemia can be a medical emergency requiring hospital admission. This article covers the management of the common causes, gives a brief overview of the rare causes and provides a strategy with which to investigate hypercalcaemia of unknown aetiology.

Treatment of type 2 diabetes

Gadsby, R. — Tue, 17 Nov 2009 06:53:10 PST

The prevalence of type 2 diabetes is rising rapidly in the UK, and most practices will now have around 4% of their registered population living with diabetes. The care of people with diabetes has in the last 20 years moved from being a largely hospital-based activity to one largely carried out in primary care (Gadsby, 2009). The Quality and Outcomes Framework of the new GP contract introduced in 2004 has provided encouragement and incentive for primary care to take on this work. All GPs and doctors training to become GPs therefore need to have an understanding of up to date diabetes management.

Insulin treatment in diabetes

Gadsby, R. — Tue, 17 Nov 2009 06:53:10 PST

Insulin therapy for people with type 1 diabetes is life saving and without insulin the condition is terminal. Insulin treatment is also needed in a significant number of people with type 2 diabetes to optimize glycaemic control. As more people with diabetes are now being managed exclusively in primary care, GPs and those training to become GPs need to have an understanding of insulin and its use in type 1 and type 2 diabetes.

AKT question relating to driving advice in diabetes

Nandakumar, M. — Tue, 17 Nov 2009 06:53:10 PST

From the Trainer

Richardson, J. — Tue, 17 Nov 2009 06:53:10 PST

Management of hypertension

Bond, R. — Tue, 17 Nov 2009 06:53:10 PST

High blood pressure (BP) is associated with an increased risk of stroke, coronary heart disease (CHD), heart failure and also an accelerated decline in both cognitive and renal function. As BP increases, so does the likelihood of these complications. In the UK, hypertension still remains undiagnosed and under treated with less than half of treated hypertensives having optimally controlled BP. A reduction of BP by an average of 12 mmHg systolic and 6 mmHg diastolic can be expected to reduce stroke by 40% and CHD by 20% (relative risk reduction).

Hypercholesterolaemia

Choudhary, F., Al-Hadithy, H., Simon, C. — Tue, 17 Nov 2009 06:53:10 PST

Cholesterol is a fatty substance manufactured by the body (mainly the liver) which plays a vital role in functioning of cell membranes. Hypercholesterolaemia is the presence of raised or abnormal levels of cholesterol in the blood. Cholesterol levels are found in a continuum within a population. Higher total cholesterol levels lead to increased risk of cardiovascular disease (CVD). Lowering cholesterol is effective for both primary and secondary prevention of all forms of CVD.

AKT question relating to blood pressure targets

Nandakumar, M. — Tue, 17 Nov 2009 06:53:10 PST

Endocarditis

Bhat, N. — Tue, 17 Nov 2009 06:53:10 PST

Endocarditis is the inflammation of the endocardium (the inner lining) of the myocardium and the heart valves. Endocarditis is a rare condition and is most commonly infective, resulting in significant mortality and morbidity from both intracardiac and systemic effects. Endocarditis occasionally presents as an acute and fulminating disease, but more often, it presents insidiously. The term ‘infective endocarditis’ (IE) is now preferred to the previously used ‘bacterial endocarditis’ as not all the infecting organisms are bacterial.

Getting a better grip on research: A simple system that works

Maskrey, N., Underhill, J., Hutchinson, A., Shaughnessy, A., Slawson, D. — Tue, 17 Nov 2009 06:53:11 PST

A complex system that works is invariably found to have evolved from a simple system that works.

John Gaule.

Church of England clergyman and author

(1603/4-1687)

This is the third paper in a series of five describing the use of evidence to support decisions made in clinical practice.

A case of faulty machinery?

Simon, C. — Tue, 17 Nov 2009 06:53:11 PST

Mr B is a 56-year-old Caucasian businessman who is usually very fit and well. He has long-standing hypertension and takes atenolol 50 mg daily, ramipril 10 mg daily and simvastatin 40 mg nocte. He has no other past medical history of note.

Write to learn: reflective practice writing

Bolton, G. — Tue, 17 Nov 2009 06:53:11 PST

Reflection is an attitude which makes the difference between 20 years of experience or only 1 year of experience repeated 20 times. Reflection is a state of mind, an ongoing constituent of practice, not a technique or curriculum element. It is a way of learning from one's own experience to inform practice, widen perspectives and challenge assumptions, taken-for-granteds and damaging social and cultural biases and a way of learning from the experience of others.

Crammer's Corner

Rughani, A. — Tue, 17 Nov 2009 06:53:11 PST

AKT answer relating to driving advice in diabetes

Tue, 17 Nov 2009 06:53:11 PST

AKT answer relating to blood pressure targets

Tue, 17 Nov 2009 06:53:11 PST

News & Views

Etherington, C., van Hecke, O. — Wed, 21 Oct 2009 08:23:01 PDT

Childhood learning disabilities

Brennand, C. — Wed, 21 Oct 2009 08:23:01 PDT

Learning disability is commonly encountered in General Practice affecting between 1 and 2% of the Western world. Patients with learning disabilities have two and a half times as many associated medical problems. It often leads to functional impairment and increased need for lifelong support involving medical services. The care of patients with learning disabilities requires a holistic approach with awareness of the services available and knowledge of the barriers to health care faced by this patient group. This article aims to outline the definitions of learning disabilities and screening and diagnosis of these conditions in primary care, causes, principles of management and the difficulties and barriers in care delivery for these patients.

Attention-deficit hyperactivity disorder

Fox, D., Scanlon, F. — Wed, 21 Oct 2009 08:23:01 PDT

Attention-deficit hyperactivity disorder (ADHD) is characterized by inattention, hyperactivity and impulsivity leading to difficulties at home, education and daily activities. ADHD remains relatively young within paediatric psychiatry with its recognition and management developing over the last 20 years. A consensus towards diagnosis and management has come with recent NICE guidelines.

AKT question relating to diagnosing attention deficit hyperactivity disorder

Nandakumar, M. — Wed, 21 Oct 2009 08:23:01 PDT

Autism and Asperger's syndrome

Ashwell, G. — Wed, 21 Oct 2009 08:23:01 PDT

Autism and Asperger’s syndrome are part of a range of conditions incorporated under the term autistic spectrum disorders (ASDs). This article will aim to define these conditions and explain the differences between them, clarify some of the myths about their aetiology and equip the reader with the specific knowledge to diagnose, refer and manage patients with ASDs as effectively as possible.

From the Trainer

Richardson, J. — Wed, 21 Oct 2009 08:23:01 PDT

Hernias

Stubbs, B., Hyder, Z. — Wed, 21 Oct 2009 08:23:01 PDT

A hernia is defined as an abnormal protrusion of a viscus, or part of a viscus, through the wall of its containing cavity. A hernia can therefore occur at many anatomical locations. Abdominal wall hernias are a common problem and prevalence of this condition has been estimated as approximately 2% for all ages. This review will concentrate on abdominal wall hernias, their presentation, diagnosis and management.

Pancreatic disease

Stephenson, J. A., Al-Taan, O., Metcalfe, M. S., Dennison, A. R. — Wed, 21 Oct 2009 08:23:01 PDT

The pancreas is a retroperitoneal organ with both endocrine and exocrine functions. It was first described by a Greek physician Herophilus between 335 and 280 BC and was given its name by Ruphos only a few hundred years later. In 1642, Wirsung discovered the pancreatic duct and within three decades Graff investigated its secretory properties. Paul Langerhans described ‘islets of Langerhans’ in 1869 and the first description of pancreatitis as a disease was by Fitz in 1889. Halstead performed the first operation on the pancreas in 1898.

AKT question relating to tumour markers

Nandakumar, M. — Wed, 21 Oct 2009 08:23:01 PDT

Liver failure

Rabindra, G. — Wed, 21 Oct 2009 08:23:01 PDT

With an increase in prevalence of alcohol abuse and obesity, cirrhosis is on the rise. To prevent progression to end-stage liver disease and liver failure, abnormalities must be picked up early. This article provides an overview of liver failure and how to approach investigation and management of patients at risk.

AKT question relating to investigating liver disease

Nandakumar, M. — Wed, 21 Oct 2009 08:23:01 PDT

Getting a better grip on research: the comfort of opinion

Maskrey, N., Hutchinson, A., Underhill, J. — Wed, 21 Oct 2009 08:23:01 PDT

Too often we ... enjoy the comfort of opinion without the discomfort of thought.

John F. Kennedy

(1917–1963)

In the 21st century, health care clinicians, managers and patients expect to see the findings of research incorporated into clinical practice, taking into account the needs and wishes of individual patients.

Nurse practitioners and general practitioners, is there any difference?

Burke, L. — Wed, 21 Oct 2009 08:23:01 PDT

Case study--lab tests that slip below the radar

Hendry, R. — Wed, 21 Oct 2009 08:23:01 PDT

Crammer's Corner

Rughani, A. — Wed, 21 Oct 2009 08:23:01 PDT

AKT answer relating to diagnosing attention deficit hyperactivity disorder

Wed, 21 Oct 2009 08:23:01 PDT

AKT answer relating to tumour markers

Wed, 21 Oct 2009 08:23:01 PDT

AKT answer relating to investigating liver disease

Nandakumar, M. — Wed, 21 Oct 2009 08:23:02 PDT

News & Views

Etherington, C., van Hecke, O. — Tue, 22 Sep 2009 12:06:03 PDT

Hand and wrist problems in primary care

Warwick, D. — Tue, 22 Sep 2009 12:06:03 PDT

Musculoskeletal disorders account for 15–20% of GP consultations and cause a significant amount of morbidity and disability. This article covers a selection of hand and wrist problems that either commonly present to the GP or are rather more rare but important, and provides a management strategy for each.

Polymyalgia rheumatica and giant cell arteritis

Knights, G. — Tue, 22 Sep 2009 12:06:03 PDT

First described in 1888 by William Bruce, a physician practising in Scotland, polymyalgia rheumatica (PMR) is an inflammatory condition of unknown aetiology. Giant cell arteritis (GCA) is a vasculitis of medium or large arteries, also of unknown cause. Because the two conditions often occur together (5% of patients with PMR develop GCA and conversely 40–50% of patients with GCA also have PMR), they are thought to share the same underlying pathophysiology, being opposite ends of the same spectrum. Unfortunately, there is no firm evidence to support this.

Inflammatory arthritis

Stevenson, J. — Tue, 22 Sep 2009 12:06:03 PDT

Inflammatory arthritis is an umbrella term used to describe a range of conditions, including rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis and reactive arthritis. These are autoimmune diseases in which joint and systemic features are present in varying degrees between disease processes and individuals. Delayed diagnosis can lead to irreversible joint destruction and dysfunction but a therapeutic revolution has transformed its prognosis. Ever-expanding therapeutic options require GPs to recognize these conditions, manage symptoms and undertake drug monitoring. The costs to individuals, their families and the National Health Service are high. There were 1.9 million GP consultations for inflammatory arthritis in 2000 and nearly 46 000 hospital admissions. The challenge in primary care is to recognize an inflammatory arthritis early and refer to secondary care.

AKT question relating to antibiotic prescribing in rheumatoid arthritis

Nandakumar, M. — Tue, 22 Sep 2009 12:06:03 PDT

From the Trainer

Richardson, J. — Tue, 22 Sep 2009 12:06:03 PDT

Patient-doctor interactions: emotional cues and discussing prognosis

Thistlethwaite, J. — Tue, 22 Sep 2009 12:06:03 PDT

The patient–doctor consultation in general practice is often an emotional interaction—for both the patient and the GP. The exchange of life stories and experiences may be joyful or sad, distressing or precipitate anger. Patients may not express their emotions in words. Depending on their personalities, reaction to distressing news and their ideas and expectations, they may say things that are dissonant from how they are feeling. The GP with good communication skills may be able to elicit the patient's feelings through a combination of intuition based on experience, previous knowledge of the patient and the patient's body language including non-verbal cues. Then the GP must acknowledge and respond appropriately to them. Non-effective communication may worsen psychological distress and delay adjustment to the disease or condition.

Breaking bad news--skills and evidence

Thistlethwaite, J. — Tue, 22 Sep 2009 12:06:03 PDT

Bad or unfavorable news may be defined as ‘any news that drastically and negatively alters the patient's view of her or his future’ (Buckman 1992). When GPs talk about breaking bad news, they usually mean telling patients that they have cancer, though in fact similar communication skills may be employed when informing patients about a positive human immunodeficiency virus status, or that a relative has died. Of key importance in the process is the doctor gaining an understanding of what the patient's view of the future is or was—the expectation that now might not be met. A doctor should not assume the impact of the diagnosis without exploring the patient's worldview.

Bereavement and coping with loss

Nagraj, S., Barclay, S. — Tue, 22 Sep 2009 12:06:03 PDT

Bereavement and loss are universal phenomena, which may be viewed as a normal rite of passage in life. Although it is important that General Practitioners do not over-medicalize death and loss, they have a valuable role in the acknowledgement of bereavement, the recognition of pathological grief and the identification of vulnerable people who may need extra support. General Practitioners may be faced with bereavement issues covering all age groups from loss of a spouse, loss of a child, miscarriage or loss of a parent. Patients also come to see GPs in the context of other losses such as redundancy, moving house, retirement and loss of fertility.

AKT question relating to bereavement

Nandakumar, M. — Tue, 22 Sep 2009 12:06:03 PDT

Getting a better grip on research: the fate of those who ignore history

Maskrey, N., Greenhalgh, T. — Tue, 22 Sep 2009 12:06:03 PDT

Those who ignore history are doomed to repeat it

George Santayana

American philosopher and poet, 1863–1952

This is the first paper in a series of five describing the use of evidence to support decisions made in clinical practice. The series covers large elements of Statement 2: The general practice consultation, Statement 3.3: Ethics and values based medicine and Statement 3.5: Evidence-based practice of the GP Curriculum.

Top tips to avoid complaints

Farquhar, A., Whitehouse, S. — Tue, 22 Sep 2009 12:06:03 PDT

Anxiety is anxiety

Turner, T. — Tue, 22 Sep 2009 12:06:03 PDT

Crammer's Corner

Rughani, A. — Tue, 22 Sep 2009 12:06:03 PDT

AKT answer relating to antibiotic prescribing in rheumatoid arthritis

Tue, 22 Sep 2009 12:06:03 PDT

AKT answer relating to bereavement

Tue, 22 Sep 2009 12:06:03 PDT