Journal of General Practice

Aim: To conduct a national survey for the First5 GPs and GP trainees to see what their future career plans are, and their views on the current issues in general practice, on a background of significant workforce problems in general practice. Method: Survey monkey was used to create an online survey that was distributed with the help of RCGP in their AiT bulletin and through their social media accounts. The links were also posted on several GP Facebook groups, Twitter and LinkedIn accounts. The survey ran between 5th of October and the 31st of October 2015. Results: 322 and 249 responses were received from First5 GPs and GP trainees respectively, just over 60% of First5 GPs and 68% of GP trainees are either definitely or possibly considering a move abroad where they feel there is a better outlook for general practice. The most popular destinations were Australia, Canada and New Zealand, a significant proportion are not considering a return to the UK. The main reasons given for early retirement were workload, job related stress, current government health care policies, working long hours, administrative work, high patient demand and risk of litigation. A majority of First5 GPs and GP trainees do not feel 7 day access to general practice is a good idea, they think the future of general practice in the UK is looking bleak and that the NHS is heading towards privatization, which the majority are against. Only about 18% of trainees would still apply for GPVTS even if 7 day GP access working was in place, 34% would consider other careers and 47% would not recommend general practice to juniors. Conclusion: Government policies, patient demands, unsustainable workload and low morale are contributing to GP trainees and newly qualified GPs in significant numbers thinking about leaving the UK general practice permanently, and changing career or retiring early. They are also less likely to recommend a career in general practice. There may need to be an urgent revie

Great is truth, but still greater…is silence about truth. …simply not mentioning certain subjects… influences opinion much more effectively than …the most eloquent denunciations. (Aldous Huxley). This essay proposes that, like all other mammals, all human groups are built around shame. In the typical idea of shame in modern societies, it is seen as triggered by some particular cultural/personal stimulus (nakedness, for example). However, there is also a universal component, set in motion by threat to the social bond. If that is the case, we need to reclaim the many fields that so far have used alternate terms, such as honor, stigma, fear of rejection, disrespect, social pain, and so on. Although there is an actual literature on shame, it is dwarfed by the many studies that use other terms. The s-word, like the f-word, is usually taboo, both in the public and in publications. This essay describes at length five fields that hide their shame content, and also, more briefly, several more. The hiding of most shame studies is further evidence of how deeply shame is still taboo in modern societies.

Synthetic cannabinoids (SC) have been increasing in popularity throughout the past decade, and are now mainstream drugs of abuse. Undetectable by many urine drug screens, SC are a heterogeneous group of chemicals with various documented side effects including myocardial infarctions, tachycardia, agitation, psychosis, nausea, and vomiting. Methods: In this case report, we present a 38 year-old female with dysphonia secondary to SC. Our patient developed dysphonia after 2.5 years of regular SC use. She was thoroughly evaluated by her primary care physician and referred to both, otorhinolaryngology and pulmonology, with an exhaustively negative workup. Her dysphonia persisted for 13 months and only improved after she abstained from using SC. Conclusions and Significance: We could find no previous cases of dysphonia or hoarseness attributed t SC use/ abuse in the literature and is yet another kind of health sequelae frontline providers should look for in chronic users of SC. The previously unrecognized relationship between SC and dysphonia demonstrates our limited understanding of the chemicals’ adverse effects. Just as nicotine affects the larynx and causes dysphonia and laryngeal carcinoma, this case also raises the question of whether the chemical composition of SC affects the larynx in the same way and its use leads to an increased risk of laryngeal cancer for users/abusers

Objective: Constipation is the most common and often most debilitating adverse effect associated with opioid use. Opioid-induced constipation persists for the duration of therapy. The aims of this clinical audit were to investigate the GP management of opioid-induced constipation, gain insights on how to improve its management and determine if the audit could improve the management of opioid-induced constipation. Methods: Using quantitative questionnaires, GPs prospectively evaluated their management of constipation in patients prescribed strong opioid analgesic for chronic non-cancer pain, across two audit cycles. The audited patients completed a quantitative survey after the initial GP visit and returned the completed survey to the GP in a sealed envelope. The patient questionnaire was used to assess consistency between patients’ and GPs’ evaluation and management of constipation. Following each cycle GPs received feedback and a decision support tool. Results: Opioid-induced constipation was reported by 50.5% of patients, but its presence was underestimated by GPs, with GPs failing to recognise opioid-induced constipation in a third of patients. GP management of opioidinduced constipation improved during the audit with improvements in the frequency of assessment and the proactive management of constipation. Conclusion: GPs need to regularly ask all patients taking opioid analgesics about the presence of constipation. Questioning should include both objective and subjective measures to assist the detection and assessment of opioidinduced constipation. The high prevalence of opioid-induced constipation necessitates proactive management at the time of opioid initiation and for the duration of opioid therapy

Japan has the world’s highest proportion of older people. To better prepare the future disaster incidents for older people, identifying challenges in the their lives is critical for effective disaster risk reduction. Technological disasters such like the nuclear power have a long- term impact on the health of the affected population than natural disasters. The purpose of this study is to gain a detailed understanding challenges of displaced older people in technological disaster situation. We carried out with twelve older people who have been moved in Tokyo. Respondents seek opportunities to talk with their friends and felt that their interactions with others were reduced. The reason why they lost their community and relationship neighbors from when they have evacuated. A majority of respondents reported that their life activities has changed after taking refuge in Tokyo.

Pancreatic cancer is the fourth leading cause of cancer deaths, being responsible for 7% of all cancer-related deaths in both men and women. Patients usually present with weight loss, epigastric pain, obstructive jaundice or development of diabetes mellitus. Unusual presentations include pancreatic rupture, depression, icthyosis etc. Presentation as upper gastrointestinal bleed is very rare in pancreatic cancer and usually occurs due to sinistral portal hypertension. We present here a case of pancreatic cancer that presented to us as upper GI bleed.

Empathy involve internal process of experiencing what is perceived from the outside world through our senses leading to imaginations and projections, so that such experience will turn the belief of “I and you” in to “I am you” or at least “I might be you”. According to Hojat, empathy in clinical practice is predominantly a cognitive attribute that involves understanding and communicating this understanding with an intention to help by alleviating pain and suffering. Unlike sympathy, empathy is trainable through experiential learning that involves all 4 domains of learning; cognitive, psychomotor, affective and interpersonal domains. Intellectual understanding of the situations (cognitive),emotional feeling and motivation (affective) results in actions with commitment (psychomotor) leading to the expression of his/her intension to help others (interpersonal). Enhancing empathy is beneficial as a parallel improvement of the professional development and patient outcomes is expected. The relationship between the intensity empathy and its beneficial outcomes has a linear relationship. However the relationship of sympathy and its beneficial outcomes shows an inverted U shape, indicating beneficial effects of enhancing sympathy progress only up to a certain limit and after that it start declining. The affective nature of sympathy leads to spontaneous reactions causing distress and deterioration of the efficacy leading to confusions and vicarious trauma. Therefore sympathetic reactions are not productive for health care professional. Empathy is a trainable attribute that contributes to the efficacy in communication, therapeutic adherence and success of treatment and finally to the satisfaction of patients as well as health care professional. Empathetic doctors are less liable for malpractice suits. Empathy promotes feeling of sameness, parallel position and respect that is conducive for patient centered attitudes. However unlike egocentric sympathy, empathy demonstrates altruism and recognizes “separateness” while retaining the feeling of sameness. The health care provider understands that the healthcare receiver is not he or her but another independent individual. Therefore empathy promotes the view that “one needs to look after themselves”. This perception motivates health care professionals to another commitment, which is to empower their patients through deliberate practices like motivational counseling. Sympathetic health care professional will focus on patient satisfaction while empathetic health care professional will focus on patient empowerment. All the religions promote empathy; understanding, feeling and supporting others to alleviate pain. Perception of separateness while experiencing the suffering of the others that will prevent attachments and vicarious trauma is also probably embedded in all regions. I have quoted explicit in examples from Buddhist philosophy due limited knowledge about teaching in other religions regarding these concepts

Tolosa Hunt syndrome (THS) is a rare cause of painful ophthalmoplegia with an estimated annual incidence of 1 case per million per year. It is caused by a nonspecific inflammatory process, of unknown etiology, involving the cavernous sinus, the superior orbital fissure and/or the orbital apex. It is classically described as an episodic orbital pain associated with paralysis of one or more of the 3rd, 4th and 6th cranial nerves, resolving spontaneously or with the commencement of steroids. I report a female patient who had 2 attacks of THS separated by a period of 10 months. She presented with retro-orbital headache, exophthalmos, and ophthalmoplegia of left eye, on both attacks, and was treated with high dose prednisolone. On first attack she improved within 6 weeks of treatment. On second attack, the patient had a higher Erythrocyte sedimentation rate (ESR) and developed 2 relapses on corticosteroids tapering, requiring a prolonged course of treatment, for 27 weeks, which suggests that the disease activity may get more severe on further attacks of the disease.

Background: Cleansing, medicating, moisturizing, and photoprotection comprise a complete acne vulgaris (AV) management regimen. However, complete topical AV treatment regimen investigations in athletes are scarce. Objective: Adapalene and benzoyl peroxide (A/BPO) gel, 0.1%/2.5% (Epiduo® Gel) is indicated for the topical treatment of AV in patients 9 years of age and older. This open-label, single-center study evaluated a regimen to cleanse, medicate, moisturize, and protect the skin comprised of A/BPO gel, Cetaphil® DermaControl™ Foam Wash and Cetaphil® DermaControl™ Moisturizer SPF 30 in student athletes (referred to as the CoMMplete Regimen). Methods: Student athletes 12 to 18 years of age with mild to moderate acne who were actively participating in 1 of 14 Texas University Interscholastic League sanctioned athletic activities followed the CoMMplete Regimen for 8 weeks (N=28). Lesion counts, satisfaction, cutaneous irritation, adverse events, and adherence were assessed. Results: After 8 weeks, lesion counts were significantly reduced compared to baseline. Good tolerability and high satisfaction were observed. Most athletes experienced no cutaneous irritation. All adverse events were mild or moderate, and the most common related adverse events were dry skin, skin exfoliation, and erythema. Most athletes exhibited exceptionally high compliance and adherence. Conclusions: The coMMplete Regimen is efficacious, safe, well tolerated, and helps optimize AV treatment outcomes in athletes.

Kingdome of Bahrain is island situated in the middle of the Gulf. The discovery of oil has led to the rapid modernization of the country and its prosperity. Such factors and other affected on the lifestyle of the population and the traditional societal role with the transformation from the large extended families to a nuclear one. One of many consequences of these changes was the increase prevalence of juvenile delinquency. In this study, there was a trial to study this phenomenon and find out the most risk factors that may help in its occurrence. The Parental Acceptance/Rejection Questionnaire, which has been translated into Arabic and was used previously with other Arab populations, was administered to a group of 30 jailed juvenile offenders and compared to a similar cohort and number of high school students with no record of delinquency. The variables, including areas related to the family conditions, were studied comparing the two groups (the delinquent vs. non-delinquent). The results indicate that there are relationships between juvenile delinquency and the parental demographic characteristics. More delinquent subjects had illiterate fathers (47%) (p<0.05) and mothers (67%), (p<0 .001) than the non-delinquent. Fifty percent (n=15) of the non-delinquents reported that their fathers were professional versus 21% of the delinquents (p<0.05). The familial relationships, conflicts, and practices were also related to the presence of delinquency. There was a less favorable interpersonal relationship between delinquents and their parents. With regards to family practices, the delinquents scored higher (1.932) than non-delinquents (1.69), indicating that the parents of delinquents were less involved in the lives of their children. Concerning emotional conflict, it was found that the delinquents scored higher (M=2.18) than non-delinquents (M=1.68); indicating more conflict was happening between their parents. In conclusion, the risks of developing delinquency in juveniles were found to be very much related to the parental interpersonal relationships, their demographic characteristics and the socioeconomic status of the family.

Background: Epistaxis is common clinical presentation to the emergency department. Initial management in mild anterior epistaxis involves manual compression of the anterior aspect of the nose. However, this step is often not done appropriately. Objective: The purpose of this article is to discuss the benefits of applying nose clips in the management of epistaxis. It can be a simple alternative to providing adequate digital compression in initial management of epistaxis. Discussion: Swimmer’s clips have been previously described in the literature for the management of mild epistaxis. The nose clip described in this article is initially designed for spirometry. This clip is user-friendly, affordable and can be easily applied to provide temporary tamponade.

Background: Pain is a serious concern in people with intellectual disabilities. They may experience many painful situations because of the lack of management of common medical problems, because of their disability-related health state and because of age-related illnesses. Literature findings: Validated tools are now available to assess pain with accuracy. People with mild and moderate intellectual disabilities are able to understand pain and they know coping strategies. Most treatments of pain relief, including psychological methods are appropriate. Conclusion: There is still room for development in clinical training and to change attitudes to improve pain management in this population.