Guideline for the prevention, diagnosis and management of cryptococcal meningitis among HIV-infected persons: 2013 update

Six years after the first Society guidelines were published, cryptococcal meningitis (CM) remains an important cause of morbidity and mortality among HIV-infected adults in South Africa. Several important developments have spurred the  publication of updated guidelines to manage this common fungal opportunistic infection. Recommendations described here include: (1) screening and pre-emptive treatment; (2) laboratory diagnosis and monitoring; (3) management of a first episode of CM; (4) amphotericin B deoxycholate toxicity prevention, monitoring and management; (5) timing of antiretroviral therapy among patients with CM; (6) management of raised intracranial pressure; (7) management of relapse episodes of CM

“10 lessons for new clinicians”

The paper will focus on the experiences and expectations of two new clinicians in their first year in legal clinic. They will draw on their own training experiences compared to the training the students receive in clinic. The paper will take the format of 10 (or maybe more!) lessons for new clinicians. A sneak preview of some of the lessons includes “How to deal with a hopeless student – its not private practice so you cannot sack them so what can you do?” and “Patience!– don’t forget that they are not trainee solicitors with full time exposure to cases like with training contracts”. The paper is intended to be light hearted yet thought provoking view of clinical practice. We hope that from this paper you will be able to reflect on your own practice as they have reflected upon their own experiences as some of the themes drawn from the paper will be common within the discipline. New clinicians will be able to learn from their experiences and also their mistakes. This paper is presented by 2 solicitors with very different experiences who moved into education in September 2007 direct from private practice. Angela Macfarlane’s qualification as solicitor was by BA honours degree, post graduate diploma in law (common professional examination -CPE), post graduate diploma in legal practice (LPC) and finally a law society training contract in private practice. For the 2 years prior to joining Northumbria University as a Senior Lecturer she was engaged in commercial and employment work, primarily acting for business clients. Prior to this her experience was with police work and crime, either representing police officers accused of criminal offences, or suing the police for civil “crimes”. Paul McKeown’s qualification was by LLB Honours (Dunhelm), post graduate diploma in legal practice (LPC) and finally a Law Society training contract. Prior to joining Northumbria University he was engaged exclusively in publicly funded work, primarily in the areas of Housing and Employment law. Paul is now employed as a Solicitor/Tutor in Northumbria’s Student Law Office

Clinician perceptions of sleep problems, and their treatment, in patients with non-affective psychosis

Aims and method: To assess clinicians’ views about their understanding and treatment of sleep problems in people with non-affective psychosis. An online survey was emailed to adult mental health teams in two NHS trusts. Results: One hundred and eleven clinicians completed the survey. All clinicians reported disrupted sleep in their patients, and endorsed the view that sleep and psychotic experiences each exacerbate the other. However, most clinicians (n = 92, 82%) assessed sleep problems informally, rather than using standard assessment measures. There was infrequent use of the recommended cognitive-behavioural treatments for sleep problems such as persistent insomnia, with the approaches typically used being sleep hygiene and medications instead. Clinical implications: Clinicians recognise the importance of sleep in psychosis, but the use of formal assessments and recommended treatments is limited. Barriers to treatment implementation identified by the clinicians related to services (e.g. lack of time), patients (e.g. their lifestyle) and environmental features of inpatient settings

Gabapentinoid use disorder. Update for clinicians

Gabapentinoids (gabapentin and pregabalin) are versatile drugs, indicated mainly for epilepsy and neuropathic pain, and have long been viewed as agents with little potential for abuse. Burgeoning prescribing patterns and studies indicate that these drugs are increasingly being abused, particularly by polydrug abusers who also abuse opioids. Gabapentinoid abuse is found in less 2% of the general population but may be as high as 15% to 22% among opioid abusers. Other risk factors for gabapentinoid abuse are less clear-cut but include mental health disorders. Gabapentinoids are relatively easy for drug abusers to obtain and many clinicians are not fully aware of their abuse potential. It is thought that gabapentinoids may offer psychoactive effects or enhance the effects of other drugs of abuse. Those who discontinue gabapentinoids abruptly may suffer withdrawal symptoms, but gabapentinoid overdose fatality is rare. Since gabapentinoids are often prescribed off-label to treat psychiatric disorders, these drugs may be dispensed to a particularly vulnerable population. Clinicians must be aware of the potential for Gabapentinoid Use Disorder: Update for Clinicians

Radical Technological Innovation and Perception: A Non-Physician Practitioners’ Perspective

Radical technological innovations, such as chatbots, fundamentally alter many aspects of healthcare organizations. For example, they transform how clinicians care for their patients. Despite the potential benefits, they cannot be integrated into practice without the support of the clinicians whose jobs are affected. While previous research shed important light on physicians’ perceptions, little is known on nonphysician practitioners view said innovations. This paper reports on a qualitative study, involving 10 nonphysician clinicians from Ontario, Canada, conducted to determine the perceptions and cognitions of clinicians regarding radical innovation and their previous experiences with technological change. Results indicate that clinicians as semi-autonomous agents can interpret and act upon their environment with regard to determining how innovations such as chatbots are implemented

Clinicians' and patients' assessment of activity overuse and underuse and its relation to physical capacity

To explore clinicians' and patients' (self)-assessment of activity overuse and underuse, and its relationship with physical capacity in patients with chronic musculoskeletal pain (CMP). Study design was cross-sectional. Participants included patients with CMP, admitted to a multidisciplinary outpatient pain rehabilitation program. The main measures used were as follows: a five-point scale to rate overuse and underuse, filled out by clinicians and patients; a five-point scale to rate physical capacity, filled out by clinicians and patients; and lifting and aerobic capacity. Cohen's kappa were calculated to test the agreement between assessments. Depending on the normality, a t-test or a Mann-Whitney U-test was used to test differences between the results of a capacity test and patients' and clinicians' assessments of capacity. A total of 141 patients were included: 42% were men, and 60% had back pain, 21% had neck pain, 19% had pain in a different location. Six percent of the patients rated themselves as underusers; clinicians rated 23% of the patients as underusers. Clinicians and patients fairly agreed (61%; kappa = 0.23) in their assessments of overuse and underuse. Differences in the physical capacity of overuse and underusers, as assessed by clinicians and patients, were all nonsignificant (P > 0.05). The physical capacity of overusers did not differ from that of underusers (P < 0.05). In conclusion, although clinicians and patients with CMP fairly agree on their assessment of activity overuse and underuse, the physical capacity of overusers was not different from that of underusers

Explaining anomalous responses to treatment in the Intensive Care Unit

The Intensive Care Unit (ICU) provides treatment to critically ill patients. When a patient does not respond as expected to such treatment it can be challenging for clinicians, especially junior clinicians, as they may not have the relevant experience to understand the patient’s anomalous response. Datasets for 10 patients from Glasgow Royal Infirmary’s ICU have been made available to us. We asked several ICU clinicians to review these datasets and to suggest sequences which include anomalous or unusual reactions to treatment. Further, we then asked two ICU clinicians if they agreed with their colleagues’ assessments, and if they did to provide possible explanations for these anomalous sequences. Subsequently we have developed a system which is able to replicate the clinicians’ explanations based on the knowledge contained in its several ontologies; further the system can suggest additional explanations which will be evaluated by the senior consultant

Setting number of decimal places for reporting risk ratios: rule of four

BACKGROUND: Visual images may facilitate the communication of pain during consultations. OBJECTIVES: To assess whether photographic images of pain enrich the content and/or process of pain consultation by comparing patients’ and clinicians’ ratings of the consultation experience. METHODS: Photographic images of pain previously co-created by patients with a photographer were provided to new patients attending pain clinic consultations. Seventeen patients selected and used images that best expressed their pain and were compared with 21 patients who were not shown images. Ten clinicians conducted assessments in each condition. After consultation, patients and clinicians completed ratings of aspects of communication and, when images were used, how they influenced the consultation. RESULTS: The majority of both patients and clinicians reported that images enhanced the consultation. Ratings of communication were generally high, with no differences between those with and without images (with the exception of confidence in treatment plan, which was rated more highly in the image group). However, patients’ and clinicians’ ratings of communication were inversely related only in consultations with images. Methodological shortcomings may underlie the present findings of no difference. It is also possible that using images raised patients’ and clinicians’ expectations and encouraged emotional disclosure, in response to which clinicians were dissatisfied with their performance. CONCLUSIONS: Using images in clinical encounters did not have a negative impact on the consultation, nor did it improve communication or satisfaction. These findings will inform future analysis of behaviour in the video-recorded consultations