Thursday, 29 September 2016

"Doctor does this mole matter?"

What would you say is the most common cancer in the UK? 
It is not lung cancer, breast cancer or bowel cancer. Nor is it prostate, ovarian or cancer of the cervix. The answer believe it or not, is skin cancer, with 100,000 new cases diagnosed in the UK each year. That’s 274 a day.
The good news is that it is both treatable, and in many cases preventable. An individual’s risk is determined by a mixture of factors including not just sun exposure, but genetics, the number of moles you have and how fair skinned you are. Doctors grade skin types by what is known as the Fitzpatrick scale, from the fair skinned ‘Type 1’ (always burns, never tans, pale white; blond or red hair; blue eyes; freckles) to the dark skinned ‘Type 6’ (Never burns, never tans, deeply pigmented dark brown to darkest brown skin). Generally your risk is higher the lower your ‘type’.
We have known for years that ultraviolet exposure (UV) from the sun is the primary cause, with sunburn being a particular trigger for changes in skin cells. The benefit of sun cream, covering up with sleeves and a hat, and generally avoiding over exposure to the sun have well established benefits. Yet still skin cancer remains at the top of the list.

‘If in doubt, cut it out’
This rather dramatic quote underlines the best treatment we have for skin cancer once it has occurred – the simple excision.
Having worked for several years Down Under, I have benefitted from a great deal of experience dealing with various spots, growths, moles and other skin lesions that crop up. In Australia, the effect of the near constant sun, combined with a relatively thin layer of ozone over the continent combine to create a very high risk of skin cancer. Compared to Europeans, Australians have a 30 times higher incidence of skin cancer. This is thought to be entirely due to sun exposure. As such, removing skin lesions is part of the daily work load for GPs there. Many cancers caught early require only a simple excision which can be done in the treatment room of a GP surgery with the proper facilities.  For myself, this meant on a daily basis I would switch between consulting in my office to removing skin lesions in the treatment room. In addition to skin cancers, more everyday skin lesions such as skin tags, unsightly moles, sebaceous cysts, and fatty lumps known as lipomas would also make an appearance.
There are 3 main types of skin cancer. The less harmful Basal Cell Carcinoma (BCC) which does not spread and can be treated easily in the early stages, is the most common. Melanoma is the aggressive, most serious type which can spread to other body areas and can be lethal, even affecting young adults. A third type, the Squamous Cell Carcinoma (SCC) can be very serious also, though benefits from early identification and excision. 
The difficulty for the average person is identifying which moles might be troublesome, and which are nothing to worry about.


How to distinguish between skin cancer and a ‘safe’ mole
One of the most effective, and evidence based way of separating the two, is to have your mole assessed by a doctor trained in dermoscopy. This is a type of assessment where the lesion is viewed through a specialised tool known as a dermoscope. The instrument magnifies and illuminates the mole, while providing polarised light which allows structures beneath the skin to be seen. With training, the worrying lesions can be separated from the safe lesions relatively quickly. It is astonishing what features and details this process reveals, while being simple, safe and painless. Picking out the ‘safe’ from the ‘dangerous’ avoids unnecessary excisions, and allows for timely intervention where there is concern.
There are some simple things to look out for which might indicate the need for a review. In general terms, any mole that is changing, whether it is growing, becoming itchy, changing colour or bleeding, should be assessed. Not all changes in well-established moles indicate cancer, but this is one of the main signals that there may be a risk. At home, a simple survey of your skin will reveal most pigmented (ie coloured) skin lesions. Particular features to look out for fit nicely in to the ABCDE rule:
  • A is for Asymmetry: One half of a mole or birthmark does not match the other.
  • B is for Border: The edges are irregular, ragged, notched, or blurred.
  • C is for Color: The colour is not the same all over and may include different shades of brown or black, or sometimes with patches of pink, red, white, or blue.
  • D is for Diameter: The spot is larger than 6 millimeters across although melanomas can sometimes be smaller than this. 
  • E is for Evolving: The mole is changing in size, shape, or color.

Visit cancer.org for more details on what to look for in your moles. We know from studies that individuals with over 100 moles are at particular risk, and it is recommended that these individuals seek a skin review every 12 months or so.

A typical excision – the ‘minor op’
If it is deemed necessary to have a mole removed, the process is relatively easy, usually involving a few simple steps.
First, there is a discussion explaining what to expect, and what the risks are. This is known as consent, ensuring the patient is well informed about the procedure. Risks are generally very low. Typically they are limited to the following:
  • Scar. Whenever the skin is cut, a scar will form. Usually this is a simple pale line once healed.
  • Infection. The risk here is low as we always use a sterile approach to even the smallest procedure. However, any time the skin is injected or cut, there remains a small risk of infection
  • Recurrence. Some skin lesions can come back, sometimes years later. The intention is to remove the lesion fully and completely, however this risk is not zero.

Once consented, the procedure involves a few typical steps. Initially the doctor is likely to mark the skin, indicating where the excision cuts will be made. Then the skin is cleaned with a surgical solution, followed by a local anaesthetic injection. The injection stings briefly (like at the dentist) but quickly numbs the region. Then the mole is removed, usually with a curved cut above and below (an ellipse). Where needed, stitches are used to close the gap, and a sterile waterproof dressing is then applied. 
Some procedures, like removing a cyst or fatty lump are a little more involved, however the general principles are the same. You are able to wash or shower with the dressing in place, and the sutures are usually removed after 7 days, when the wound can be checked.

Getting checked
Oxford Private Medical Practice we offer assessment of skin lesions with dermoscopy, and where needed, excision including pathology assessment, meaning our colleagues in the laboratory examine the tissue closely to determine specifically the diagnosis. In addition, we can offer excision of moles, skin tags, cysts, scars – really any skin lesion which is causing distress or discomfort. There are some sites which require more specialist intervention than can be offered in primary care setting, and so an assessment is needed before planning any surgery. However, minor operations for everyday skin lesions are simple, relatively painless, and can provide excellent results without the need for a lengthy wait to see a hospital specialist, or a prolonged recovery stage.
If you are concerned about a particular mole, would like to have a skin lesion removed, or simply want peace of mind from a full skin check, feel free to contact the surgery to book an appointment.


Sunday, 5 June 2016

Vaccination: quick and (almost) painless

Following on from my last blog regarding the HPV vaccination and how it has benefits for both boys and girls, it is interesting to see that new guidelines have been developed to help doctors and nurses who inject children.  These guidelines focus on how we can reduce distress for the child.
As a parent, and a GP, I am very familiar with the stress that comes with having one of your children vaccinated.  There’s no escaping the fact that for a brief moment, the jab is going to cause a prick or a sting, and all we can do is comfort our children and distract them if possible, safe in the knowledge that we have acted in their very best interests.  It is always over very quickly and soon forgotten, but the lead up to vaccination day can be a source of anxiety.  Mums and Dads sometimes find the process too tough to handle, and we frequently see the task delegated to Grandparents or one parent in particular, no doubt after much personal deliberation!

Why are the guidelines important?
I hope it will be encouraging to hear that a great deal of thought and investigation has gone in to how a child receives their vaccination.  What on the surface may appear to be a quick jab, actually involves some considered thought on how we can make the process as free from distress as possible. The guidelines I mentioned have been prepared by the Royal Australian College of General Practitioners.  They provide a focused reminder for healthcare workers on how to give the best service in this important role. 
Knowledge of pain prevention and management techniques has been shown in clinical studies to reduce pain, fear and distress in the child.  What’s more, being armed with some information as the parent, and involving older children in some discussion prior to the vaccine, can also improve the experience.

The Guidelines
The guidelines begin with a reminder that vaccination is the most common cause of iatrogenic (ie caused by the doctor) pain in childhood.  What follows is a list of the recommendations and the strength of evidence available for each. I have summarised the recommendations below with some brief explanation:

The Process of Injecting
Avoid aspirating
Typically when a nurse or doctor injects, we will insert the needle and then draw back a little to make sure the tip is not inside a blood vessel.  The aim is to place the vaccine fluid in the muscle where it is absorbed. However, this takes a little longer and causes slightly more pain.  As long as the needle is correctly placed, it is not needed in childhood vaccination.

Simultaneous injecting
As alarming as it may sound, it is less distressing for a young child to have 2 needles at once rather than one after another.  This usually means one needle in each thigh provided by 2 practitioners, but is not always practically possible.

Leave the worst until last
It is known that unfortunately some vaccines are a little more uncomfortable than others.  Whether young or old it has been shown that the best process is to leave the most painful jab until last.

Where to inject
Up to one year of age the thigh is generally better tolerated than the upper arm.

Physical considerations
Sitting upright and being held
In children over three years, sitting upright provides more comfort than lying flat.  In younger children, holding close during the injection, and rocking or patting afterwards reduces distress.  These often seem natural and occur without prompting in many cases.

Skin to skin contact
For the very youngest babies, this most natural situation is most effective, typically with the baby in a nappy held to the upper chest.

Sucking
Either with a dummy, bottle or even breast feeding, reduces pain and distress.

Distraction
The final advice provided focuses on the benefit of distraction.  This should be appropriate to the age of the child.  Video and toy distractions work well with young children, whereas breathing techniques, music and verbal distraction may yield better results with older children.  Babies tend to benefit from a sweet solution in addition to other distractions, with breast feeding being the ultimate example of this.

So there we have it.  Some of the recommendations are common sense and occur naturally during the vaccination process, however preparation and knowledge of these techniques has the potential to reduce distress significantly.  Rest assured we keep these in mind whenever we see a child for their vaccination as our goal is the same as yours – make it quick and (almost) painless.

With best wishes

Dr James Hunt

Saturday, 14 May 2016

HPV vaccine (Gardasil) - not just for girls

Preventing cancer.
Anyone with a teenage daughter will be familiar with a relatively new vaccination provided in year 8 at school, which is designed to protect against cancer of the cervix. In the UK this is the second most common cancer to affect women under the age of 35, with around 3000 cases per year (8 cases per day) being diagnosed. Unfortunately death rates are high - around 970 women died from cervical cancer in 2011 in the UK.
The jab, GARDASIL, represents a truly dramatic improvement in healthcare. Just consider what this vaccination gives us – a proven and effective vaccination against a form of cancer. We often hear about the search for a cure for cancer, and here we have one step better – true prevention. No wonder it has become a routine childhood vaccination across developed countries all over the world.

But what about the boys?
Clearly boys and men are not at risk of cancer of the cervix, but there are very real benefits to boys being vaccinated too. For now however, the national immunisation program provided by the NHS only covers girls. In time, as in Australia, it will very likely be extended to males, but the wait means there is a population of boys missing out.

In order to understand how boys might benefit from the vaccination, it helps to understand what it vaccine does. Gardasil essentially protects individuals from a virus, namely human papilloma virus, or HPV.  We have long known that HPV is causative in over 70% of cervical cancer, but it is also known to cause vaginal and vulval cancers too. The majority of the adult population have been exposed to this virus through sexual contact as it is very common, and this is why we have cervical screening tests – to detect any cancer change in the general female population. Like many cancers, exposure to one of the causes does not mean you WILL develop cancer, but if you have not been exposed, you are very UNLIKELY to.
The Gardasil vaccine protects against the virus, and this explains why it is given before children mature and become sexually active.
The good news is that in boys there is also a benefit to be had. HPV is an established cause of anal cancer and genital warts (80% and 70% of cases respectively). Where a male has been protected by the vaccination, the risk of these illnesses dramatically falls. These are distressing, uncomfortable and unpleasant diagnoses to have, and it is fantastic that they are now preventable in a large number of cases.

What do the authorities say?
There is a lot of information available online regarding Gardasil and other HPV vaccinations. Much of this can be found on their website, but for truly impartial advice the Centres for Disease Control and Prevention is a resource that cannot be beaten. This is a US based public health institution which focuses on health protection and safety. You will have heard the name in the news many times as they are an authority typically providing international guidance on disease outbreaks globally. The CDC recommends 
“routine vaccination with GARDASIL for boys and girls ages 11 or 12. The CDC also recommends vaccination for young women ages 13 through 26 and young men ages 13 through 21 who have not already been vaccinated.”
Cancer research UK has a very informative page on HPV and vaccination, including advice of the benefits to boys, but recognising the cost of vaccinating all boys would be high, which may be a reason it is not yet available through the NHS.

Further benefits on the horizon – throat cancer
HPV is in fact a group of viruses, with over 150 different types. The vaccine targets those which we know can cause genital cancer and genital warts. An area of increasing interest surrounds cancers of the head and neck.  These cancers are increasing, especially in the male population with 3 or 4 men for every woman affected. Some centres suggest the ratio is much higher, with 6 or 7 times as many men than women affected. Research has shown that again, HPV is a primary cause. Estimates vary on the exact proportion for which HPV infection is the cause, however it may be as high as 70%. Alcohol and smoking are the prime causes where HPV infection is not detected. The total number of HPV related throat cancers has increased 4-5 fold in the past 10 years, and it is believed that HPV infection is the most likely reason for this increase.
Fortuitously, Gardasil vaccination targets HPV 6, 11, 16 and 18 and it is HPV 16 which causes the majority of infection related throat cancers.
As this was not the initial aim of the vaccination, research on benefit in terms of preventing throat cancer is only now starting to emerge. It has, however, been proven that the vaccine does prevent the infection, and it is expected that in time studies will reveal a reduction in throat cancers in this group. It is males who will benefit most as they are at far greater risk here.

Prevention not treatment
In both boys and girls it is important to realise the vaccination cannot provide treatment once the illness has occurred – it is a preventative and needs to be provided in childhood or early teenage years.
I routinely advise that HPV vaccination provides a fantastic advantage to both girls and boys, and recommend it to my suitable patients. For me, it is one of the highlights of healthcare development in recent years.

Gardasil is given as 3 injections over 6 months or 2 injections if given between the ages of 11-14. If you would like to arrange vaccination for your child, or want to discuss this or any other vaccination further, please feel free to come and see us for an appointment.

With best wishes

Dr James Hunt

Wednesday, 27 April 2016

My child won't stop coughing!

We have all no doubt noticed how coughing among children is practically the norm, especially in pre-schoolers. At any one time, research suggests that parents will report coughing in nearly a third of children. What’s more, the impact can be significant: poor sleep, reduced performance at school, parental anxiety, even a household awake all night long.
The most common cause is an acute viral Upper Respiratory Tract Infection (URTI) which healthy children experience several times each year. A quarter of these will continue to have a cough 2 weeks after the infection, possibly longer.
Assessment and treatment of cough  is an area under continuous review by the guiding medical bodies, most notably the British Thoracic Society.

Information on the internet about cough is generally inaccurate
As GPs we often view the internet as a double edged sword. It can be invaluable as a source of useful information for self-management, however misinformation is everywhere. A study was set up to investigate this revealing that out of 19 web pages identified giving information about cough, over half contained more ‘incorrect’ than ‘correct’ information, and only 1 was ‘mainly correct’. Choose your sources wisely!

Types of cough
 In General Practice we tend to consider cough in 2 groups:
Acute cough – less than 3 weeks duration, and Chronic cough, from 3 to 12 weeks, though this is a simplification.

Acute Cough
Acute cough is the type seen in the healthy child with a viral URTI. These tend to recover without any medical intervention. Symptoms can be eased with the use of inhaled steam or cough linctus. Complications are rare, and can be predicted to an extent by the presence of certain features including fever, breathlessness, and findings when examined such as crackles in the chest. Viral URTI is contagious and can spread through a classroom or playgroup. 
Particular examples of viral respiratory infections include Croup, where a young child develops a characteristic ‘barking’ cough, and bronchiolitis caused by a virus known as RSV, which is seasonal and again affects infants. 
Other causes of acute cough are Lower Respiratory Tract Infection (LRTI, commonly referred to as a ‘chest infection’), Allergy, Inhaled Foreign Bodies eg food or a small piece of a toy, and very rarely serious underlying disorders such as Cystic Fibrosis.

Chronic cough
Cough due to infection such as those seen in acute cough can sometimes become prolonged, lasting even up to 8 weeks. This is usually due to recovery after a virus, known as ‘post-viral’ cough, or sometimes childhood bacterial infections such as Whooping Cough. The commonest cause of the chronic cough remains respiratory tract infection. 
Whooping Cough itself is underdiagnosed. A study of school aged children presenting to their GPs with a cough lasting more than 2 weeks found that a third had strong evidence on testing of recent Whooping Cough infection. 90% of the children tested had completed their normal childhood vaccinations including the Whooping Cough vaccination. Whooping cough therefore is something we always consider when seeing a child with a prolonged cough.
Other causes of chronic cough are varied, and identifying them requires careful review of how symptoms developed, a thorough examination and sometimes investigations. 
Asthma can present as a cough alone, though more commonly s seen with wheezing and shortness of breath.
Gastro-oesophageal reflux, where acid and stomach contents leave the stomach and rise up the gullet causing irritation, is a rare cause.
Psychogenic cough is the term used to describe a cough that has become a habit. This usually occurs after a true URTI, however it lasts long after the infection has cleared. It is characterised by being dry and repetitive, and by fading in the evenings when the child is distracted. This sort of cough is safe but can only be diagnosed when other causes have been appropriately ruled out.

Serious causes of cough
These are rare, but as GPs we look out for certain ‘red flags’ that may prompt us to investigate further. As a parent it is wise to seek a review if any of the following symptoms are occurring in your child:
  • Cough from newborn
  • Chronic ‘wet ‘ cough
  • Cough which started with a choking episode
  • Cough when being fed
  • Cough where the child is not growing well
  • Coughing up blood
  • Recurrent chest infections

When do we use antibiotics?
Antibiotics do not provide any benefit when used to treat a cough caused by a virus. These make up the majority of short duration acute cough and so where a child is otherwise healthy, antibiotics are not generally used. If the cough appears to be caused by infection and has lasted despite simple supportive measures, antibiotics may be required, especially where particular infective causes like Whooping Cough are suspected. The same is true if a child is particularly unwell, as this may indicate pneumonia where infection involves the tissue of the lung and not simply the airways. Antibiotics will also be used more readily where a child has other serious health problems such as heart disease or prematurity.
It is very important to remember that a cough caused by a simple virus can last as long as 3 weeks, however this in itself is not a reason to start antibiotics.

When is a cough not a cough?
Occasionally a child will come to see a GP with a cough which turns out to be ‘throat clearing’. This is rather different to a cough but not always immediately obvious. Throat clearing tends to occur with the mouth closed, and lacks the hard edge of a cough. 
A common cause for throat clearing is allergy, usually hay fever, and as such is typically treated with antihistamines and related medicines that can reduce mucus production that can irritate the back of the throat. 

Ask if you are uncertain
We can all expect to see our children have a cough from time to time. As always though, it can be difficult as a parent to gauge how your child is doing. If they are unwell and you are at all unsure, or simply want peace of mind, an assessment is generally straightforward with investigations only occasionally being required. We see children with cough daily, and recognise how troubling it can be. 

Best wishes

Dr James Hunt

Tuesday, 15 March 2016

How to help your child deal with anger - Dr Kirren Schnack Clinical Psychologist

All human beings get angry. We’re supposed to, evolutionarily speaking it helps us to survive when our fight or flight options get restricted down to the former. But anger can of course also be damaging, it can overwhelm us, especially when we’re under-experienced at anger management.

Why does my child get so angry at everything?
Children are a pot of boiling emotions, with little experience of how to deal with their emotions in moderation. This is actually a physiological situation – your little darling’s frontal cortex (where he or she does their thinking, planning, and decision-making) is still in the process of growth. So, emotionally-speaking, they’re like a car heading out into the world without a fully-configured braking system. While they can go from 0 to 10 on the anger-meter in appropriate situations, they can hit the same anger peaks in situations where they haven’t actually been threatened in any meaningful way, and this can seem as though it is disproportionate.
Certain feelings can be very threatening – grief, hurt, confusion, humiliation, fear – and anger is your child’s way of putting up defensive shields. If your child doesn’t learn any other way of dealing with these threatening feelings then anger becomes their go-to method for dealing with them. Needless to say, this is not a healthy way for children to interact with the world.

Anger Management Tips for your Child

1. Help your child develop a healthy Emotional Intelligence Quotient.
It’s looking more and more like a high EQ plays a massive role in determining a human being’s quality of life – even higher than a person’s IQ (Intelligence Quotient).
What is EQ? It’s a combination of understanding why you are feeling something, having empathy for the feelings of others, and the ability to process your own feelings in order to have a purposeful talk about what you or another is feeling.
Many adults don’t know how to have a conversation about their feelings. It’s that much worse for children who don’t have the vocabulary and probably don’t know that such conversations are even a thing.
  • Developing a child’s EQ can start right from infancy. Respond quickly to crying – this develops trust in you as a caregiver, which in turn develops a sense of security.
  • Practice anger management on yourself. Calm yourself. Children are unconscious emotional divining-rods – if you’re calm, it will calm them. If you’re anxious, you’re adding fuel to the fire.
  • Give them a healthy model for dealing with big emotions, by modelling this yourself.
  • Give them the tools to soothe themselves. This is a physiological process – babies that are soothed properly grow nerve pathways that aid in self-soothing. Without this early start it becomes harder for toddlers to learn how to calm themselves.
  • Teach them decision-making. You can’t choose how you feel but you can choose how you act on those feelings.
  • Get them talking about their feelings early on, try to use emotion words as often as possible, make them part of their everyday vocabulary. Anger management is going to be much easier for you and your child if opening up about their feelings is just part of their life; for example, maybe you can make it part of their going-to-bed routine.
  • Allow your child to have his or her feelings. Let him or her know they are not bad or wrong for how they feel. Keep in mind this is not the same thing as giving the green light for physical lashing out – you’re saying that you recognise that Holly is angry at her little brother, not that you think it’s okay that she made him eat sand.
  • Don’t dismiss their feelings. If they’re squeamish about playing with a certain other child, don’t tell them to just get over it. See if you can find out why these feelings exist – there can very well be something very real behind the feelings.
  • Don’t try to divert them from what they’re feeling. “Young ladies don’t yell,” isn’t helpful. Anger management requires that feelings be acknowledged and empathised with.
  • Don’t get to your own yelling stage. If you see a problem arising, interject yourself early instead of getting to the point where you’re angry. If you do get to the yelling stage then what you have are two people in fight mode instead of a parent and a child who are able to have a conversation. When you notice that things are heading that way, say you need a time-out/breather, then go and take a break, walk around the garden, deep breathing in the bedroom, a cup of tea, whatever your strategy is now is the time to use it.
  • Find out what the anger is defending your child from. Anger management isn’t really just about managing anger – it’s also about managing grief, fear, anxiety, envy and so on… all the triggers that ignite the anger.
  • Don’t solve the problem for them. It’s the old “teach a man to fish” analogy – if you solve every trigger problem yourself you won’t be giving them the tools that they’ll need to “fish” (problem-solve) later in life. Aid them, absolutely, but make sure that they’re part of the solution.
2. Set a good anger management example.
Constantly yelling at your children? Then that’s the behaviour your children will carry with them for the rest of their lives. If Mum and Dad don’t go into fight mode over the small stuff, then their children won’t need to either.

3. Be a source of happiness and stability.
Part of anger management is giving your child the chance to experience the full range of emotions, including happiness and stability. Set up a routine (stability) where it’s you-and-him/her, on a one-to-one basis, enjoying an activity together, without anyone else, make this a regular part of your life, maybe a few times a week. It doesn’t have to be big things, it can be simple things that you can take from your daily routine.

4. Let the steam out of your ears, not out of your mouth.
We keep coming back around to this point in different ways because it’s so important – if you blow up, the situation blows up, and your child learns nothing healthy from the experience. Your child is never going to learn to look for the underlying trigger feelings (fear, grief, etc.) if they’re defending themselves from
your anger (by getting angrier).

5. Give them the ability to stop the anger before it starts.
A very helpful facet of dealing with anger is the ability to recognise triggers in one’s own self. If you can help your son or daughter recognise their own growing irritation or annoyance (pre-anger symptoms) then they’ll stand a much better chance of switching to the favoured frontal cortex before the anger becomes full-blown.

6. Allow all the feelings! But only some of the actions.
Feelings are allowed. Violent actions based on those feelings are what need to be curtailed. If feelings get locked away there’s no way for your child to examine or explain them to you. Then they burst out without any sort of control and next thing you know you’re apologising to some parent because your darling child just stomped on their child’s lunch-box.
Set limits, children want limits. If they’re limitless, then they’re actually going to feel worse if they throw a stone through a window because they know that’s something that bad people do, which means that they are a now a bad person.

7. Give them the childhood anger management equivalent of your bubble bath.
You have your own way of letting off steam – a bubble bath, you go jogging, maybe you dig a hole in the garden and scream obscenities into it, whatever. Part of your child’s anger management is that they need some kind of physical actions that are green-lighted by you so they can feel safe when they’re letting it all out. Punching their little sister on the arm is a no-no.
Make an actual list with your child. Let them be the one to do the actual writing (or maybe add illustrations if they can’t write yet). Post it on the fridge. Zen gardens, dancing, poetry with really bad rhymes, stomping hard to loud music, explore ways to physically get the anger out. Some of them will make you both laugh, and some you’ll find will fit your natures perfectly.

8. Make sure they know you’re there for them.
We’re not just talking anger management here, we’re talking everything management. Sadness, frustration, whatever, keep some physical contact with them as a reminder that you’re there to help. Say out loud that it’s okay that they’re dealing with some big emotions, say the word, whether it’s feeling sad, angry, scared, annoyed, say it.
If they tell you to go away, back off a bit, but be close and maintain your presence until they’re ready to discuss what’s going on. Do not send them off on their own – this is isolation and loneliness added on top of whatever else they’re going through emotionally.

When do I need professional anger management help?
If you’ve tried everything and your child is still a ball of continuous fury who is striking out then please don’t feel ashamed at the need for professional help. Sometimes all it takes is for an additional set of eyes with a bird’s-eye view of the situation to get you set on the right path.
Psychologists don’t just listen. They’ll help you create concrete goals for you and your child to work towards together.
If you have any questions at all we’d be delighted to answer them. Get in touch with us via our contact page. 
Here are some signs that your child may need professional help to deal with their anger:
  • They redirect anger towards easy (generally smaller) victims (smaller children, animals).
  • Physical violence towards others outside of brothers and sisters (sibling rivalry is another whole topic).
  • He or she can only express their relationships (including towards him or herself) in terms of negative emotions and hatred.
  • There’s no down-time on the anger – it’s always seems to be lurking, ready to explode.
  • Vandalism and damaging property, including things in the home.
  • Automatically goes into a contrary stance about anything and/or everything – “The sky is blue.” “No it’s green!”
  • Threats of hurting him or herself, or actual physical harm to self (head-butting, hitting self in the face, banging head on a wall).
  • It’s never his or her fault, they’re always think someone else is to blame.
  • They experience revenge fantasies, how they can get back at those who have angered them.
  • He or she struggles to keep friendships with children his/her own age, and/or struggles to get along with other adults.

If you would like help or advice we offer appointments for children and adults at the practice in Summertown. Please call the practice for more information or visit our website.

Dr Kirren Schnack 

Monday, 14 March 2016

Will general practice as we know it survive in this economic climate?

We are not sure.  Below is a document written by a local GP colleague who is trying to raise awareness of the pressure that NHS GPs are under.  Reading it, I am struggling to see how the wonderful NHS GP service that we know and love is going to survive.  We are posting it to help with awareness as we fully support our NHS GP colleagues and believe that the role of GP is such a crucial one to this nation.  Here it is:



£136 per year – what can you buy?

- 11 months pet insurance; it costs £151 to insure one rabbit for a year with Petplan
- 6 months mobile phone use; one year on a Vodafone sim-only tariff costs £264
- 5 months Sky TV family bundle 
- less than 3 tanks of fuel for a Vauxhall Astra
- coffee on your way to work for 3 months

Or…

…one year of funding per patient for the average general practice.

Yes. £136. Less than the cost of pet insurance, or a mobile phone, or Sky TV, or 3 tanks of fuel. And many practices get far less than this.
And what do you get for your £136?
  • As many consultations with your GP or other practice staff as you need
  • Prescriptions organised and signed
  • Blood tests
  • Other tests e.g. ECGs
  • Hospital referrals
  • Pre-hospital care
  • Post-hospital care
  • Home visits if required
GPs use this money to:
  • Pay for their premises
  • Pay doctors and nurses
  • Pay their reception and admin staff
  • Pay for electricity, gas, phone bills
  • Buy/maintain surgery equipment and drugs
  • Pay for CQC inspections
  • Pay for accountancy, legal advice
  • Pay for professional insurance
It’s not much, is it?

GP funding has fallen by nearly 1/3 in the last five years.
General practice is in crisis – without better funding, we cannot continue.

What can you do to help?

  • Please don’t waste appointments. If you can’t make your appointment, cancel in good time
  • Think about if you really need an appointment – could the pharmacist help?
  • Order your repeat prescriptions in good time rather than at the last minute
  • Only request a home visit if you are genuinely housebound
  • Contact your MP. Tell them how much you value your GP surgery

Dr Amanda Northridge
Medical Director 

Monday, 25 January 2016

Preventative medicine? What really works?

There is much debate about whether population screening for medical conditions is really useful in the long run.  When you look at the figures for screening performed on healthy people it is amazing what a small chance you have of both picking up some sort of health problem and of prolonging and saving a life as the result of a screening test.  Huge numbers of people have to go through procedures, all with some sort of risk, to produce an incredibly small change in the overall chance of saving or prolonging life.

That being said there are a few things that I believe are worthwhile in terms of preventative medicine.  Here are three simple ones that come to mind:

1.  To me, preventing pregnancy when you don't wish to have a baby is the by far the most significant intervention that you can make in the life of your patient.  I am amazed at the privilege that we, as a nation, have in being able to choose when we wish to have a baby.  And these days there are great improvements in the types of contraceptives available.  Take the contraceptive ring, widely used across Europe, which only needs to be remembered on two days a month, the day you put it in and the day you take it out.  And preventing pregnancy, with all the risks to health that pregnancy entails, turns out to be a worthwhile health prevention intervention.

2.  Vaccine preventable diseases are another form of preventative medicine that I can really believe in.  We now effectively have two anti-cancer vaccines, not widely known as such but both the hepatitis B vaccine and the HPV vaccine prevent cancer.  In Australia and the US and many parts of Europe Hep B is given on the national immunisation program at birth.  Hep B is transmitted by blood to blood route and so can be picked up by treading on a used needle on the beach, it can also be sexually transmitted.  And hep B causes liver cancer in a small percentage of people who are infected with the virus. So to me, that is an obvious one.  Less well known is that the HPV vaccine, currently only given to girls in the UK but also to boys in other parts of the world, has reduced the incidence of head an neck cancers as well as cervical cancer in women.   As well as these vaccines the annual flu vaccine does a great job of reducing your chance of catching flu, the whooping cough vaccine given throughout life reduces the chance of whooping cough.  The Australians have got this one sorted - you need a whooping cough vaccine to get a visa to go there these days - they have realised that the 100 day cough is worth preventing at all costs.

3.  I have always thought that an annual glaucoma eye test has to be worth it.  A little puff of air into the eye gives you a measure of the pressure within your eye.  A raised pressure within the eye can cause gradual but permanent loss of vision if left untreated and it's such an easy test.  I suggest it to all my patients once a year after the age of 50.

There are lots of other health prevention tips that are worth thinking about.  I am forever reminding my patients to keep fit, drink less and manage stress in their lives.

Wishing you a happy and healthy 2016

Dr Amanda Northridge