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The Practitioner

The Practitioner contributes to the formal clinical literature and is primarily aimed at GPs, with subscribers throughout the world. All articles in The Practitioner online include CPD frameworks for personal reflection on learning and drafting of plans that will have an impact on practice. Preset search links to PubMed and NICE Evidence are associated with most major articles.

 

Symposium articles

Diagnosis and management of vascular dementia

24 Jun 2022Paid-up subscribers

Vascular dementia describes chronic progressive impairment of cognitive function arising from cerebrovascular injury. The presentation of vascular dementia is often insidious, with disorganisation, loss of drive, irritability, mental rigidity, difficulties with planning and problem solving, emotional lability and other mood changes, and sometimes inappropriate or disinhibited social behaviour. Physical examination may identify gait impairment, bradykinesia, rigidity, and focal neurological signs. 

Assessing and managing depression in patients with dementia

24 Jun 2022Paid-up subscribers

The relationship between depression and dementia is complex. Depression appears to be an independent risk factor for incident dementia, conferring a two-fold increase in dementia risk. Depression may represent an early sign or prodromal feature of dementia. The association between depression and dementia appears to strengthen as the interval between the two disorders shortens. Depression may also be a consequence of dementia.

Diagnosis and management of acute coronary syndrome

25 May 2022Registered users

The term acute coronary syndrome (ACS) describes a range of conditions, including unstable angina, non-ST-elevation myocardial infarction (NSTEMI) and ST-elevation myocardial infarction (STEMI), which are associated with a sudden reduction of blood flow to the heart. Its presentation is broad, and can include chest pain, cardiac arrest, haemodynamic instability, or cardiogenic shock. Urgent assessment of patients presenting with chest pain is crucial to the outcome as ACS treatment is time sensitive.

Optimising the recognition of Lewy body dementia

25 May 2022Registered users

Lewy body dementia is a heterogeneous condition that is often difficult to treat. It is associated with higher rates of neuropsychiatric symptoms, inpatient admission and carer stress, as well as shorter survival, than other dementia subtypes. Core clinical features are: fluctuating cognition with pronounced variations in attention and alertness; recurrent visual hallucinations; REM sleep behaviour disorder; one or more features of spontaneous parkinsonism. Recurrent visual hallucinations occur in up to 80% of patients.

 

Special reports

Pulmonary rehabilitation key in chronic respiratory disease

24 Jun 2022Paid-up subscribers

Pulmonary rehabilitation improves breathlessness and health status in a range of conditions. It is a multifaceted programme of exercise training, disease education and self-management. Many programmes also provide psychological support and advice about breathing control training and nutrition. All patients who complete a pulmonary rehabilitation programme should have a written programme for ongoing exercise, with or without a referral to a community exercise facility. Patients may need to repeat the programme after 1-2 years, as the benefits may diminish over that period.

Improving cardiovascular outcomes in type 2 diabetes

25 May 2022Registered users

Type 2 diabetes reduces life expectancy by up to 10 years and around half of all patients die from cardiovascular disease (CVD). NICE advises that in patients whose QRISK2 score is 10% or higher and those with established CVD, an SGLT2 inhibitor should be used early on. For those patients initially assessed as not having established CVD or a QRISK2 score of 10% or higher, at each assessment two factors should be considered: if the HbA1c target has been achieved and whether their CVD risk has changed.

Maintain a high index of suspicion for kidney cancer

25 Apr 2022

More than 50% of renal cell carcinoma (RCC) cases are detected incidentally on imaging, often at a late stage. Patients may present with mass-related localised symptoms, constitutional symptoms and symptoms of metastatic disease. Ultrasound is the optimal initial investigation to screen individuals with suspected RCC. NICE recommends that patients aged 45 and over with isolated haematuria, in the absence (or following treatment) of a urinary tract infection, are referred for investigation of a potential renal malignancy.

Diagnosing and managing Alzheimer’s disease

25 Mar 2022Registered users

Although there are a number of phenotypes of Alzheimer’s disease dementia, by far the most common is amnestic. Impairment of new learning, forgetting recent activities or conversations, is particularly prominent whereas memories of early life and knowledge are not affected until later. The posterior cortical atrophy variant is characterised by prominent visual disturbance not explained by other pathology; the logopenic primary progressive aphasia variant is dominated by language deficits. Visual and language symptoms can be present relatively early in the amnestic variant, but are not predominant.

Diagnosis and management of deep vein thrombosis

24 Jan 2022Registered users

Symptoms of deep vein thrombosis (DVT) typically consist of unilateral leg swelling, redness, pain and discomfort, and are usually of acute onset. However, symptoms are variable and can be minimal in up to 50% of patients. The symptoms and signs are non-specific, and only a third of patients with a clinical suspicion of DVT have the condition. A thorough history and careful examination will help rule out other causes. Patients with suspected DVT should have a Wells score performed in combination with a D-dimer assay. 

Holistic approach needed to manage postherpetic neuralgia

20 Dec 2021Registered users

Postherpetic neuralgia (PHN) is defined as pain persisting for greater than three months following the onset or healing of herpes zoster. It may present as a continuation of pain following the acute pain of acute zoster reactivation, commonly referred to as shingles, or following a period of being pain free. Rarely PHN may develop without a classical herpetic rash (zoster sine herpete).

 

Care of the elderly

Diagnosis and management of age-related macular degeneration

25 Jan 2021Registered users

Age-related macular degeneration (AMD) is a cause of painless, gradual loss of vision. Epidemiological evidence suggests 4-8% of people aged over 65 years in the UK have visually significant AMD. Patients with suspected neovascular AMD (NvAMD) should be seen by ophthalmology within two weeks, and if the diagnosis and progressive disease are confirmed, treatment should commence within the same timeframe. Intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents cause regression of neovascularisation and reduce macular oedema. There is no treatment for dry AMD.

Diagnosing anxiety disorders in older adults can be challenging

25 Jan 2021Registered users

In older adults, the prevalence of anxiety disorders is higher among those with other health problems, and those in hospital and care settings. A primary depressive disorder should be excluded whenever an older person presents with anxiety symptoms for the first time, and comorbid anxiety often indicates a more severe presentation of depression. Around four in five patients have a comorbid physical disorder. Medical conditions can mimic symptoms of, predispose to, or even directly precipitate an anxiety disorder, and may colour its symptomatology or limit treatment options.

Elderly onset RA: a diagnostic and therapeutic challenge

23 Jan 2020Registered users

Elderly onset rheumatoid arthritis (EORA) is defined as rheumatoid arthritis (RA) with age of first onset 65 years or over. It comprises an acute onset proximal or large joint arthritis with a prominent systemic syndrome characterised by constitutional symptoms and a higher ESR than in the younger patient with RA. Investigations should focus on trying to establish the cause and ruling out differential diagnoses. They should include inflammatory markers, serum uric acid, full blood count, rheumatoid factor/anti-CCP antibodies, and X-rays of the affected joint as well as the hands and feet. The possibility of malignancy should always be borne in mind. NICE recommends urgent referral of all suspected cases.

 

Musculoskeletal medicine

Treating to target will optimise long-term outcomes in RA

24 Nov 2020Paid-up subscribers

Rheumatoid arthritis (RA) classically causes a symmetrical, small joint polyarthritis which left untreated can lead to joint destruction and deformity. NICE recommends that any adult with suspected persistent synovitis of undetermined cause should be referred for a specialist opinion. Patients should be referred urgently (even with a normal acute-phase response, negative anti-CCP antibodies or rheumatoid factor) if any of the following apply: the small joints of the hands or feet are affected; > 1 joint is affected; there has been a delay of ≥ 3 months between onset of symptoms and seeking medical advice.

Diagnosis and management of Paget’s disease of bone

24 Nov 2020

Paget’s disease of bone is a metabolic disease in which focal abnormalities of bone remodelling occur in one or more skeletal sites. The affected bones enlarge and may become deformed and this can lead to complications including bone pain, pathological fractures, secondary osteoarthritis, deafness and nerve compression syndromes. The three main risk factors are age, male gender and family history. People with a first-degree relative with Paget’s disease have a seven-fold increased risk of developing the disease. Patients who have bone deformity or symptoms that might be due to Paget’s disease should be referred to secondary care. 

 

Gastroenterology

Early treatment can arrest or reverse cirrhosis

24 Jul 2020Paid-up subscribers

Around 60,000 people in the UK are estimated to have cirrhosis. It is now the third most common cause of premature death. Decompensation represents a watershed moment for patients with cirrhosis, with the median survival falling from > 12 years for compensated cirrhosis to approximately two years. Patients with cirrhosis should undergo six-monthly ultrasound to screen for the early development of primary hepatocellular carcinoma. They should also undergo an initial upper gastrointestinal endoscopy to screen for varices.

Tailor treatment to the patient with gallstone disease

24 Jul 2020Paid-up subscribers

Gallstones affect around 15% of adults in the UK. Between 50 and 70% of patients with gallstones are asymptomatic at diagnosis and only 10-25% of these individuals will go on to develop symptomatic gallstone disease. The vast majority (90-95%) of gallstones are cholesterol stones. Obesity is associated with an increased risk of symptomatic gallstones. Patients with symptoms suggestive of gallstones should be offered liver function tests and an abdominal ultrasound.

 

Psychiatry

Early recognition key in child and adolescent anxiety disorders

23 Apr 2020Registered users

Anxiety disorders are common, highly treatable conditions, with a strong evidence base for cognitive behaviour therapy. In a recent population sample of the under 12s, only 65% of those who met criteria for a diagnosis of an anxiety disorder had sought professional help and only 3.4% had received an evidence-based treatment. Assessment should include an exploration of neurodevelopmental conditions, drug and alcohol misuse, and speech and language problems.

Treating psychological trauma in the real world

23 Jan 2020Registered users

After a potentially traumatic event (PTE), many individuals experience either no distress or only transient distress, while others suffer considerable morbidity and may develop post-traumatic stress disorder (PTSD). Around one-third of people experiencing a PTE will develop PTSD, though this varies depending on the type of traumatic event and rates of PTSD are higher with type 2 trauma. Type 2 trauma involves repeated traumatic experiences over extended periods. Although PTSD symptoms can be present acutely, the diagnosis requires the persistence of symptoms for at least one month and the symptoms should cause functional impairment.

Early intervention key in first episode psychosis

20 Dec 2019Paid-up subscribers

Psychosis is a state of mind in which a person loses contact with reality in at least one important respect while not intoxicated with, or withdrawing from, alcohol or drugs, and while not affected by an acute physical illness that better accounts for the symptoms. Common positive symptoms of psychosis include delusions and hallucinations. These symptoms are strongly influenced by the underlying cause of the psychosis: delusions in schizophrenia tend to be bizarre; delusions in depression negative; delusions in mania expansive. When a patient presents with psychotic symptoms, it is important to take a full psychiatric history, perform a mental state examination and complete relevant investigations, as indicated in each individual case.

 

Neurology

Detailed history the cornerstone of epilepsy diagnosis

24 Sep 2020

The incidence of epilepsy in the UK is estimated to be 50 per 100,000 per year and up to 1% of the population have active epilepsy. The diagnosis of epilepsy will usually be made in a neurology clinic. A generalised seizure as part of a generalised epilepsy syndrome may occur without warning but may be preceded by blank spells or myoclonic jerks. A generalised seizure with focal onset may be preceded by an aura. Brain imaging is required in almost all cases where epilepsy is suspected, the only possible exception being people with generalised epilepsies proven on EEG. MRI is the imaging modality of choice.

GPs should be vigilant for acute deterioration in myasthenia gravis

24 Sep 2020Registered users

Myasthenia gravis is an autoimmune disorder of neuromuscular junction transmission. It is relatively rare, with an approximate annual incidence of 1 per 100,000 population, and prevalence of 15 per 100,000 population in the UK. An ocular presentation may include fatiguing ptosis or diplopia. Typically, symptoms ‘fatigue’ (the physical power of the muscle deteriorates rapidly with repeated activity) and become more noticeable as the day progresses. More generalised symptoms include fatiguing difficulty with speech or swallowing. There may be fatiguing weakness of the arms and legs. The diagnosis will usually be confirmed by referral to a neurologist. 

 

Women's health

GPs have a key role in the management of miscarriage

22 Mar 2021Registered users

First trimester miscarriage affects up to one in four pregnancies. While some women will experience bleeding and pain, others have no symptoms and are given the diagnosis at their 12-13 week booking scan. In 50-85% of cases the cause is due to a spontaneous chromosomal abnormality, most commonly trisomy. Many women suffer from psychological sequelae including PTSD, anxiety and depression. GPs should offer a follow-up appointment to all women who have had a miscarriage to: discuss any questions the woman has regarding her miscarriage; assess the woman’s psychological wellbeing and offer counselling if appropriate.

Have a high index of suspicion for ectopic pregnancy

24 Mar 2020Registered users

Ectopic pregnancy is estimated to occur in 1-2% of all pregnancies and continues to be the leading cause of maternal mortality in early pregnancy. Most ectopic pregnancies are located within the fallopian tube and carry a risk of tubal rupture and intra-abdominal bleeding. Women with ectopic pregnancy can present in a wide variety of ways, from acute collapse following rupture to asymptomatic and unaware that they are pregnant. Symptoms may include vaginal bleeding and abdominal pain. There may also be non-specific symptoms such as Gl and urinary symptoms, rectal pressure, dizziness, shoulder tip pain, fainting or syncope. 

Investigating the cause of heavy menstrual bleeding

25 Mar 2019Registered users

Heavy menstrual bleeding has been defined as ‘excessive menstrual blood loss which interferes with a woman’s physical, social, emotional, and/or material quality of life’. Heavy menstrual bleeding affects 25% of women of reproductive age and is estimated to be the fourth most common reason for gynaecological referrals. Women should be asked about pelvic pain which might suggest endometriosis and pressure symptoms which might suggest significant fibroids. Examination is appropriate if there is intermenstrual or postcoital bleeding and, if the woman is actively bleeding, may identify the source of the bleeding.

Symptom recognition key to diagnosing endometriosis

22 Mar 2018Registered users

Endometriosis affects around one in ten women of reproductive age in the UK. NICE guidance highlights the importance of symptoms in its diagnosis. A normal abdominal or pelvic examination, ultrasound, or MRI should not exclude the diagnosis. Endometriosis should be suspected in women and adolescents who present with one or more of: chronic pelvic pain, significant dysmenorrhoea, deep dyspareunia, period-related or cyclical GI or urinary symptoms, or infertility. If endometriosis is suspected or symptoms persist, patients should be referred for further assessment.

 

CPD exercises associated with each issue

CPD exercise - June 2022

24 Jun 2022Paid-up subscribers

All articles in The Practitioner online are associated with fillable PDF frameworks for personal reflection on learning and for the drafting of plans for CPD. These templates are also included here in our standard study pack containing this month’s CPD exercise plus all relevant articles: • Diagnosis and management of vascular dementia • Assessing and managing depression in patients with dementia • Pulmonary rehabilitation key in chronic respiratory disease

CPD exercise - May 2022

25 May 2022Paid-up subscribers

All articles in The Practitioner online are associated with fillable PDF frameworks for personal reflection on learning and for the drafting of plans for CPD. These templates are also included here in our standard study pack containing this month’s CPD exercise plus all relevant articles: • Optimising the recognition of Lewy body dementia • Diagnosis and management of acute coronary syndrome • Improving cardiovascular outcomes in type 2 diabetes

CPD exercise - April 2022

25 Apr 2022Paid-up subscribers

All articles in The Practitioner online are associated with fillable PDF frameworks for personal reflection on learning and for the drafting of plans for CPD. These templates are also included here in our standard study pack containing this month’s CPD exercise plus all relevant articles: • Improving the early detection and management of prostate cancer • Prompt diagnosis of epididymo-orchitis can prevent complications • Maintain a high index of suspicion for kidney cancer

 

Case report

A case of maternally inherited diabetes and deafness

24 Feb 2022Registered users

Maternally inherited diabetes and deafness (MIDD) is a rare form of diabetes, affecting an estimated 0.1-0.2% of patients with diabetes in the UK. Affected women pass the condition on to both daughters and sons. However, affected men cannot pass the condition on to any of their offspring. It has high penetrance, with more than 85% of carriers developing diabetes during their lifetime. Bilateral sensorineural hearing loss occurs in most cases. The hearing loss typically develops in early adulthood and often precedes the onset of diabetes.

 

Editorials

Surgery versus nonoperative treatment for Achilles’ tendon rupture

24 Jun 2022Registered users

Although nonoperative treatment for Achilles' tendon rupture produced similar outcomes to surgery (minimally invasive or open repair) with respect to patient-reported and clinically assessed function, rerupture rates were substantially lower in patients who underwent surgery, a study from Norway has found.

Psychological interventions with physiotherapy for low back pain

25 May 2022Registered users

Behavioural therapy delivered with physiotherapy, mainly structured exercise, was the most effective treatment in reducing pain in patients with chronic, non-specific low back pain, a systematic review and network meta-analysis has found. Pain education with physiotherapy produced sustainable improvements in physical function and fear avoidance.

 

Research reviews - by GPs with a special interest

OCD associated with increased risk of substance use disorder

24 Jun 2022Registered users

Patients with obsessive-compulsive disorder (OCD) are nearly four times more likely to develop substance use disorder than those without OCD, a Swedish cohort study has found. This association may be partially attributed to genetic factors, but environmental factors may also be involved.

Why do patients with COPD delay seeking medical care for exacerbations?

24 Jun 2022Registered users

Reluctance to seek care is a common response to exacerbations in patients with COPD. Excessive self-reliance, not wanting to bother healthcare professionals and waiting for a tipping point when the exacerbation became more severe were reasons cited by COPD patients for not seeking medical care sooner, in a qualitative study from the USA.

All grades of aortic stenosis raise risk of death

24 Jun 2022Registered users

Even mild aortic stenosis is associated with an increased risk of mortality, a large study from Australia has found.

 

HASLAM's view

How do you tackle stress?

24 Jun 2022Registered users

Some years ago, I tried using a simple stress diary when I was going through a particularly rough patch. The technique may sound like some sort of Californian psychobabble, but it certainly helped me.

Does being a patient make you a better doctor?

25 May 2022Registered users

However kind, empathetic, and experienced we might be, doctors still tend to be rather poor at genuinely understanding what the experience of ill health is like.

 

Cancer - Temporary direct access

Maintain a high index of suspicion for kidney cancer

25 Apr 2022

More than 50% of renal cell carcinoma (RCC) cases are detected incidentally on imaging, often at a late stage. Patients may present with mass-related localised symptoms, constitutional symptoms and symptoms of metastatic disease. Ultrasound is the optimal initial investigation to screen individuals with suspected RCC. NICE recommends that patients aged 45 and over with isolated haematuria, in the absence (or following treatment) of a urinary tract infection, are referred for investigation of a potential renal malignancy.

Improving the early detection and management of prostate cancer

25 Apr 2022

Prostate cancer is the most common cancer in men in the UK. In men with possible symptoms of prostate cancer, an assessment of LUTS, relevant risk factors and past medical history is essential. NICE recommends performing a DRE; this will give an impression of prostate size. If the prostate feels malignant on DRE this should trigger a fast-track referral to secondary care, via a suspected cancer pathway referral even if the PSA is normal. A PSA test should also be offered to men with LUTS or an abnormal DRE.

Risk stratification key to management of basal cell carcinoma

27 Oct 2021

Basal cell carcinoma (BCC) is a slow growing, locally invasive malignant epidermal skin tumour. Metastases are very rare and morbidity results from the localised destruction of tissue particularly on the head and neck. Suspected high-risk BCCs on the central face (around the eyes, nose, lips and ears) should be referred for an urgent opinion. BCCs most commonly present on the head and neck and sun-exposed sites but may occur at any body site. Patients will often report a non-healing wound that recurrently bleeds, crusts and scabs but does not heal.

Early detection of cutaneous melanoma improves prognosis

24 Sep 2021

Exposure to intermittent intense sunlight and sunburn (especially in childhood) are the most common modifiable risk factors for melanoma. Individuals with lighter skin tones are at greatest risk (Fitzpatrick skin types I-II). A history of melanoma increases the risk of a further melanoma eight-fold. Approximately 5-10% of melanoma cases are estimated to be familial. The 7-point checklist is recommended by NICE to help determine when a referral is indicated. However, checklists should not be used in isolation as some melanomas will be missed. Amelanotic melanomas, estimated at 10% of all melanomas, remain a challenge. 

Prevention, diagnosis and treatment of colorectal cancer

26 Jul 2021

Colorectal cancer is the third most common cancer in both women and men and is the second most common cause of cancer death in the UK. The main symptoms patients with colorectal cancer present with are: persistent blood in faeces; persistent change in bowel habit and persistent lower abdominal pain. Less obvious presentations are unexplained weight loss, tiredness for no reason, general malaise and iron deficiency anaemia found on blood testing.

Improving the detection of cutaneous squamous cell carcinoma

25 Jun 2021

Cutaneous squamous cell carcinoma (cSCC) can develop de novo or from pre-existing chronic actinic damage, although the probability and speed of transition from actinic keratosis to cSCC is highly variable. The occurrence of cSCC is related to chronic UV exposure, particularly occupational exposure. Risk factors include fairer skin, significant exposure to sunlight or PUVA. Incidence is also significantly increased in patients who are immunosuppressed. All patients with suspected cSCC should be referred via the two-week wait pathway to dermatology.

GPs should have a high index of suspicion for testicular cancer

22 Apr 2021

Most men with testicular cancer present with a lump that they have identified in their scrotum. Although the scrotal swelling is usually painless, pain is the first symptom in around 20% of patients, typically a dull or dragging ache in the testicle or a heaviness in the scrotum. NICE recommends that all men who have a non-painful enlargement or change in shape or texture of their testis should be referred urgently to urology using the two-week wait pathway. In men who have unexplained or persistent testicular symptoms, an urgent direct access testicular ultrasound scan should be requested. 

Diagnosis and management of malignant pleural mesothelioma

21 Dec 2020

Mesothelioma accounts for less than 1% of all cancers in England, Wales and Northern Ireland. There are almost 2,500 new diagnoses a year, of which 96% are pleural. The median age at diagnosis for malignant pleural mesothelioma (MPM) is 76 years. The majority of cases occur in men, most commonly following occupational exposure to asbestos. There is a latent period, usually 30-40 years, between exposure and disease development. A chest X-ray is usually the first-line investigation; 94% of patients with MPM have a unilateral pleural effusion, although the chest X-ray may be normal or show another asbestos-related lung disease. 

Time to diagnosis key in improving lung cancer outcomes

25 Nov 2019

NICE recommends urgent referral via a suspected cancer referral pathway to the two week wait service if: chest X-ray findings suggest lung cancer or if patients aged 40 and over have unexplained haemoptysis. However, studies have indicated that around 20-25% of patients with confirmed lung cancer may have a chest X-ray reported as normal and this figure may be higher for early stage lung cancers. Therefore, the National Optimal Lung Cancer Pathway recommends that where there is a high suspicion of underlying malignancy (but the chest X-ray is normal), GPs should refer patients directly for a CT scan.

Early detection of liver cancer key to improving outcomes

07 Aug 2019

Hepatocellular carcinoma (HCC) accounts for around 90% of liver cancer cases and intrahepatic cholangiocarcinoma (CC) for 9-10%. Most cases of HCC occur in the context of chronic liver disease with cirrhosis, particularly in those with chronic hepatitis B or C. Other major risk factors include excessive alcohol consumption, obesity and aflatoxins. Overall, 10-15% of cirrhotic patients will develop HCC within 20 years. Patients presenting with an upper abdominal mass consistent with an enlarged liver should be referred for an urgent direct access ultrasound scan within two weeks. 

Improving outcomes in pancreatic cancer

25 Jul 2018

The combination of an aggressive disease, vague presenting symptoms and insensitive standard diagnostic tests is a key factor contributing to poor outcomes with only 15% of patients with pancreatic cancer having operable disease at diagnosis. The NICE guideline on referral for suspected cancer recommends urgent referral via a suspected cancer pathway referral if the patient is aged 40 and over with jaundice. It also recommends that an urgent direct access computerised tomography (CT) scan referral should be considered in patients aged 60 and over with weight loss and any of the following: diarrhoea; back pain; abdominal pain; nausea; vomiting; constipation; new onset diabetes. Pancreatic cancer requires a CT scan for diagnosis.

Diagnosis and management of oesophageal cancer

22 Feb 2018

Oesophageal cancer commonly presents with dysphagia or odynophagia and can be associated with weight loss and vomiting. Referral for urgent endoscopy should always be considered in the presence of dysphagia regardless of previous history or medication. NICE recommends urgent referral (within 2 weeks) for direct access for upper GI endoscopy in patients with dysphagia and those aged 55 years or over with weight loss and any of the following: upper abdominal pain, reflux, or dyspepsia.

 

A hundred and fifty years ago

150 years ago: Insufficient food: an accidental cause of chorea

24 Jun 2022Registered users

As starvation had had much to do with the precipitation, at least, of the chorea, so did generous food in hospital very quickly produce an impression both upon the choreic state and upon the mental condition. But she went back to her poverty-stricken home for two years, and at the end of that time was prematurely forced into the slavish toil of a maid-of-all-work in a small tradesman’s family. The consequence was very remarkable: she was observed to become somewhat fidgety in her movements and sly and furtive in her gestures; and before she was sixteen she had passed (without any full re-development of the choreic affection) successively through the stages of prostitution and of religious melancholia, in which latter she settled down: the youngest of such patients that I have seen.

 

A hundred years ago

100 years ago: The effect of suggestion on nervous disease: two case reports

24 Jun 2022Paid-up subscribers

Mrs A. was a stout lady, about 45, who was the mother of a family of twenty, all alive. Her husband had met with some business reverses, and they had to give up their house in London. She stated her present condition came on gradually until she lost power of her lower extremities. In reply to my question, if there and then taken out of bed what did she think would happen, she said if she attempted to stand, her legs would give way and she would collapse on the floor. In every other way she was healthy. On examination, there was no atrophy or rigidity of the muscles; the knee-jerks, though faint, were present. Sensation was, as well as I can remember, not affected.

 

Comment/Letters

Comment: How well do you think you know your patients?

24 Jan 2022Registered users

Professor Haslam mentions the value of the fresh pair of eyes that a medical student or trainee in the practice brings, and I would like to add the benefits of locums.