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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

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.

Prompt diagnosis of epididymo-orchitis can prevent complications

25 Apr 2022Registered users

Epididymo-orchitis is an inflammation of the testis and epididymis, generally of infectious origin. In young men epididymo-orchitis is most often associated with sexually transmitted infections. In those aged over 35 the causative pathogens are more likely to be non-sexually transmitted coliform organisms associated with urinary tract infections. Other causes include viral infections such as mumps in immunocompromised, non-immunised or prepubescent males, local trauma, and medication such as amiodarone. 

Complications following termination of pregnancy

25 Mar 2022Registered users

Serious complications during or after termination of pregnancy are rare. However, they can be associated with significant morbidity and mortality, and occasionally can complicate future pregnancies. The risk of pelvic infection is around 10% and this is usually due to exacerbation of a pre-existing infection. The most common causes of bleeding include: retained products of conception; infection and trauma to the cervix or uterus, especially at > 10 weeks’ gestation. 

GPs have key role in identifying women at risk of pre-eclampsia

25 Mar 2022Registered users

Pre-eclampsia is an important cause of maternal morbidity and mortality. It is a multisystem disorder of pregnancy characterised by new onset hypertension after 20 weeks’ gestation, usually accompanied by proteinuria. If a urine dipstick is positive for protein, the amount should be quantified: a protein: creatinine ratio = 30 mg/mmol is abnormal. There should be a high index of suspicion for pre-eclampsia if there is biochemical disturbance consistent with the diagnosis or evidence of fetal growth restriction when plotted on a customised growth chart.

Optimising the management of children with cystic fibrosis

24 Feb 2022Registered users

Cystic fibrosis (CF) is an autosomal recessive disorder resulting from two disease-causing mutations in the cystic fibrosis transmembrane regulator (CFTR) gene located on chromosome 7. CFTR is a chloride and bicarbonate channel found in sweat glands and the epithelial cells of the respiratory and digestive tracts. CF is the most common life-limiting genetic disorder in the UK, diagnosed in one in every 2,500 babies. The median age of death in the UK has been rising steadily and is 36 years. Most deaths in young people are the result of rapidly progressing lung disease. Use of CFTR modulators has resulted in a step change in CF management, improved lung function and will help to improve survival. CFTR modulator therapy targets the underlying CFTR defect.

Diagnosis and management of osteogenesis imperfecta

24 Feb 2022Registered users

Osteogenesis imperfecta is a group of rare inherited skeletal disorders characterised by a greatly increased risk of fragility fractures. The reduction in bone strength is due to defects in its material properties and mineralisation. Low trauma fractures typically start in infancy e.g. as a consequence of falling when learning to walk. Rarely mild osteogenesis imperfecta can present for the first time during adulthood. Diagnosis is primarily clinical, based on a history of multiple low trauma fractures during infancy and childhood, and other clinical features.

GPs should be vigilant for accelerated progression of CKD

24 Jan 2022Registered users

Despite being common, CKD often remains undiagnosed partly because of lack of symptoms until late in the disease process. Late detection of CKD, and hence lack of effective management, increases the risk of progression to end-stage renal disease which often requires renal replacement therapy such as dialysis or transplantation. Derangement in serum creatinine and eGFR will alert a clinician to a patient with potential CKD. Timely referral for specialist nephrology input when required is key.

Suspected nephrotic syndrome warrants urgent referral

24 Jan 2022Registered users

Nephrotic syndrome results from dysfunctional glomerular filtration and consists of three clinical features: severe proteinuria (> 3.5 g/24 hr); hypoalbuminaemia (serum albumin < 30 g/L); and peripheral oedema. It may occur in people of all ages. If nephrotic syndrome remains uncontrolled even those with normal kidney function at presentation can develop progressive chronic kidney disease. All patients with suspected nephrotic syndrome should be referred urgently to nephrology.

 

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.

 

Special reports

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.

 

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 - 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

CPD exercise - March 2022

25 Mar 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: • GPs have key role in identifying women at risk of pre-eclampsia • Complications following termination of pregnancy • Diagnosing and managing Alzheimer’s disease

CPD exercise - February 2022

24 Feb 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 osteogenesis imperfecta • Optimising the management of children with cystic fibrosis • A case of maternally inherited diabetes and deafness

 

HASLAM's view

The patient turns the tables on her psychiatrist

25 Apr 2022Registered users

She looked at him, and then at me, and then she said: ‘You think I’m mad! You come round to my house with the sole intention of locking me away under a section and you think I’m going to offer you a chocolate éclair. It’s you who’s mad! Stark staring mad.’

Taken to task by a teenage cancer patient

25 Mar 2022Registered users

‘Can I ask you something?,’ he said. ‘Of course,’ I replied. He looked serious. ‘Well then, David,’ he said, ‘Could you tell me why GPs are so f***ing useless?’

 

Editorials

Lung cancer screening improves early detection and survival

25 Apr 2022Registered users

Following the introduction of lung cancer screening in the USA there has been a stage shift towards patients being detected with early disease and improved survival, a large US study has found.

Multimorbidity in midlife linked to higher risk of dementia

25 Mar 2022Registered users

Developing two or more chronic conditions in middle age has a strong association with an increased incidence of dementia later on, 30-year follow-up data from the Whitehall ll study has shown.

 

Research reviews - by GPs with a special interest

Steroid plus lidocaine injection improves pain and function in hip OA

25 Apr 2022Registered users

Addition of a single ultrasound guided intra-articular injection of triamcinolone and lidocaine to advice and education for hip osteoarthritis was associated with greater improvement in hip pain and function over six months compared with advice and education alone, a UK study has found.

Asthma education reduces hospitalisations in children

25 Apr 2022Registered users

Asthma education reduces the frequency of hospitalisation and visits to emergency departments and clinics in children, a meta-analysis has found. Education involving both children and parents/guardians was more effective than that involving only children.

Concomitant steroid therapy raises GI bleeding risk in AF patients on DOACs

25 Apr 2022Registered users

Oral glucocorticoids are associated with an increased risk of gastrointestinal bleeding in patients with atrial fibrillation concomitantly treated with direct acting oral anticoagulants, a nationwide study from Denmark has found.

 

Cancer - Temporary direct access

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.

Prompt investigation improves outcomes for kidney cancer

22 Feb 2018

Renal cell carcinoma should be suspected in the presence of: localising symptoms such as flank pain, a loin mass or haematuria; constitutional upset including weight loss, pyrexia and/or night sweats; or unexplained test results. Smoking, obesity and hypertension are common risk factors and all three demonstrate a dose-response relationship with the relative risk of renal cell carcinoma.

 

A hundred and fifty years ago

150 years ago: A case of severe neuralgia treated with phosphorus 150

25 Apr 2022Registered users

The patient, a lady aged about 25, had suffered more or less from sick-headache or migraine from girlhood. After her marriage she had children rapidly, and being weakened in consequence, the attacks had become more frequent and violent, and had changed somewhat in character, having assumed more the character of distinct neuralgia of the first division of the fifth nerve, a common transformation. Change of air afforded relief from the attacks for a while, but as soon as she had been a short time in any place in England they began to return. She enjoyed a more complete immunity when at sea or abroad,  and during two or three journeys to the Orkneys, and on one to Malta, Egypt, and other parts of the Mediterranean, and for some time after her return she had not a single attack.

 

A hundred years ago

100 years ago: Examination of a sleeping baby for intussusception

25 Apr 2022Registered users

One seats oneself at the side of the bed, and if the child is asleep so much the better. Slipping the warm hand under the bedclothes, one lays it on the abdomen of the child, and waits. Quite often without doing anything else the tumour will be felt to harden, and the diagnosis is made then and there. If no peristalsis is felt, slight movements should be made with the fingers to induce it, when it can at once be felt.

 

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.