Aust Fam Physician
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The review of a doctor's fitness to practice is being increasingly discussed internationally. The Medical Board of Australia has recently announced a desire to explore this issue. The United Kingdom (UK) introduced revalidation for doctors last year. The UK revalidation system is an enhancement of the National Health Service appraisal system that requires doctors to participate in annual appraisals conducted by trained peers. The appraisal process involves four stages: submission of a range of information; a confidential appraisal discussion; a personal development plan; and a post-appraisal sign-off. The criteria that doctors are assessed against are detailed in the General Medical Council's guidelines of Good Medical Practice. Satisfactory participation in the appraisal process over a 5-year cycle is likely to result in a recommendation for successful revalidation. ⋯ The revalidation process has been beneficial from a personal perspective, but the range of consequences and subsequent support mechanisms need to be considered and addressed.
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Neck pain is a common presentation in general practice. Nevertheless, recommendations for the investigation and management of neck pain lack a strong evidence base and are predominantly extrapolated from low back pain studies. ⋯ Although sinister causes of neck pain are rare, clinicians must be mindful of red flags that may indicate serious pathology. The medical interview, rather than the physical examination, remains the most critical step in determining the likely cause of cervical spine pain, whereas biochemical tests and imaging are not part of routine assessment. The classification of neck pain into acute or chronic patterns, extrapolated from the low back pain literature, may help stratify the need for intervention and the likely prognosis of neck pain. A more concerted research effort is needed to help better understand and develop evidence-based guidelines for the management of neck pain.
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Review
SGLT2 inhibition with dapagliflozin -- a novel approach for the management of type 2 diabetes.
Because of the progressive nature of the disease, most patients with type 2 diabetes mellitus eventually require multiple treatments to achieve glycaemic targets. The majority of available therapies are insulin dependent, aiming to decrease insulin resistance and increase insulin secretion. Sodium glucose co-transporter 2 (SGLT2) inhibitors, a new class of antidiabetic agents, limit renal glucose reabsorption promoting urinary excretion of glucose, thereby reducing plasma glucose. ⋯ Clinical trials have shown dapagliflozin to be effective in reducing glycosylated haemoglobin, weight and fasting plasma glucose, either as monotherapy or as add-on therapy to metformin, sulphonylurea and insulin. Other SGLT2 inhibitors are currently under investigation.
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Peripheral arterial disease (PAD) is a manifestation of systemic atherosclerosis. It affects 10-15% of the general population, and is often asymptomatic; leading to under-diagnosis and under-treatment. Atherosclerotic risk factors are often not intensively managed in PAD patients. ⋯ Careful history, clinical examination, and measurement of ankle-brachial index remain the initial means of diagnosing PAD. More detailed anatomic information from duplex imaging, computed tomography angiography and magnetic resonance angiography, is usually unnecessary unless endovascular or surgical intervention is being considered, or if abdominal aortic aneurysm or popliteal aneurysm need to be excluded. Management is focused on lifestyle modification, including smoking cessation and exercise; medical management of atherosclerotic risk factors, including antiplatelet agents, statins, antihypertensive therapy; and agents to improve walking distance, such as cilostazol and ramipril. Endovascular or surgical interventions are usually considered for lifestyle limiting intermittent claudication not responding to conservative therapies, and for critical limb ischaemia.
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Even after a thorough examination it can be difficult to distinguish a normal penile anatomical variant from pathology needing treatment. ⋯ The problems considered include pearly penile papules, penile sebaceous glands (Fordyce spots), Tyson glands, angiokeratomas of the scrotum, lymphocoele, penile warts, molluscum contagiosum, folliculitis and scabies.