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The Practitioner

The Practitioner is a PubMed indexed journal, primarily aimed at GPs, with subscribers throughout the World. It is also used by doctors preparing for work in the UK. 

All articles in The Practitioner online include CPD fillable PDF 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: Gastroenterology

Diagnosis and treatment of inflammatory bowel disease

01 Aug 2016Registered users

Patients with inflammatory bowel disease (IBD) may previously have received a diagnosis of irritable bowel syndrome and there may be a delay in making the correct diagnosis. This is particularly the case in patients with ileal Crohn’s disease and those under 40. Diagnosis of IBD involves endoscopy and biopsy. Approximately 25% of people with IBD will have extra-intestinal manifestations of the disease, involving skin, eyes, joints or the liver. There is an increased risk of colorectal cancer in patients with ulcerative colitis.

Improving the detection of coeliac disease

01 Aug 2016Registered users

The common presentation of coeliac disease has shifted from the historically classical symptoms of malabsorption in childhood to non-classical symptoms in adulthood such as irritable bowel syndrome-type symptoms, anaemia, chronic fatigue, change in bowel habit, abdominal pain and osteoporosis. A combination of coeliac serology and duodenal biopsy is required to diagnose coeliac disease in adults. A lifelong strict gluten-free diet is the only effective treatment currently available. All patients should be referred to a specialist dietitian for guidance and support.

 

 

Special reports

Identifying patients with complex PTSD

01 Aug 2016Registered users

Type 2 or complex trauma results from multiple or repeated traumatic events occurring over extended periods. Complex trauma is often associated with other adversity and stressors such as neglect, loss or deprivation. For many individuals these traumas occur at a developmentally vulnerable time with the perpetrator often in a caregiving role. Patients who have experienced complex trauma should be assessed for the core symptoms of PTSD. In addition, patients should be assessed for disturbances in the three domains of emotional dysregulation, negative self-concept and interpersonal disturbances.

Have a high index of suspicion for meningitis in adults

01 Aug 2016Registered users

Bacterial meningitis and meningococcal sepsis are rare in adults. Any diagnostic delays with subsequent delay to treatment can have disastrous consequences. The classic triad of neck stiffness, fever and altered consciousness is present in < 50% of cases of bacterial meningitis. Patients with viral meningitis also present with signs of meningism (headache, neck stiffness and photophobia) possibly with additional non-specific symptoms such as diarrhoea or sore throat. Suspected cases of meningitis or meningococcal sepsis must be referred for further assessment and consideration of a lumbar puncture.

 

Clinical Reviews

GP interventions help patients discontinue benzodiazepine therapy

01 Aug 2016Registered users

Primary care intervention programmes were more effective than standard care in helping patients achieve long-term abstinence from benzodiazepines, a study from Spain has shown. Patients aged 18-80 years from primary care centres, were enrolled in a three-arm, randomised controlled trial. All 532 patients had used prescribed benzodiazepines daily for at least six months, mostly for anxiety and insomnia. The median age of patients was 64 years and 72% were female. Overall the intervention programmes were 1.5 times more effective than standard care in helping patients achieve abstinence.

Proactive care improves functioning in chronic depression

01 Aug 2016Registered users

Practice nurse-led structured care of adult patients with chronic or recurrent depression achieved a modest improvement in functional impairment but did not significantly improve depression scores or quality of life, a randomised controlled trial has found. The ProCEED (proactive care and its evaluation for enduring depression) trial recruited participants from 42 general practices throughout the UK. Overall, 276 patients were allocated to the control group (GP treatment as usual) and 282 to the proactive care intervention.

 

Diabetes

Improving the detection and management of type 1 diabetes

25 Jan 2016Paid-up subscribers

Type 1 diabetes affects around 370,000 adults in the UK, about 10% of all those diagnosed with diabetes. In type 1 diabetes there is a lack of beta cell insulin secretion as a result of autoimmune destruction of the beta cells. However, patients are not affected by insulin resistance, and so do not routinely experience the features of metabolic syndrome that occur in type 2 diabetes. It is therefore important to classify the type of diabetes correctly and to recognise that type 1 diabetes is a condition with its own management requirements. Structured education is the cornerstone of care providing tools to allow effective self-management.

Improving outcomes in diabetes in pregnancy

21 May 2015Paid-up subscribers

One in 250 pregnancies in the UK involves diabetes. The majority of cases (87.5%) are gestational diabetes, 7.5% are type 1 and 5% are type 2 diabetes. Diabetes in pregnancy is associated with a five fold increase in risk of stillbirth and a two-fold increased risk of congenital defects compared with the general maternity population. Women with gestational diabetes have a significant lifetime risk of developing type 2 diabetes, hence diabetes screening must be undertaken on an annual basis in primary care.

 

Painful conditions

Evaluating the patient with low back pain

22 Dec 2015Paid-up subscribers

In the UK, low back pain is the most common cause of disability in young adults and every year 6-9% of adults consult their GP about back pain. A thorough history and examination is required to exclude an alternative diagnosis, such as pain arising from the hip or trochanteric bursa and to categorise patients as having: serious spinal pathology, nerve root/radicular pain or non-specific back pain. [With pre-set searches of the evidence base]

Diagnosing shoulder pain

01 Jan 2009Paid-up subscribers

The prevalence of shoulder disorders has been reported to range from 7 to 36% of the population accounting for 1.2% of all GP consultations. Shoulder pain has been said to be the second most common musculoskeletal complaint presenting in primary care. On average GPs are consulted approximately seven times each week for a complaint relating to the neck or upper extremity; three of these consultations will be for new complaints or new episodes. [With external links to the evidence base]

 

Cardiovascular medicine

Management of heart failure with preserved ejection fraction

21 Oct 2015Paid-up subscribers

Heart failure affects nearly one million people in the UK. Half of these patients have normal, or near normal, left ventricular ejection fraction and are classified as heart failure with preserved ejection fraction (HFpEF). Newer imaging techniques have confirmed that systolic function in HFpEF patients is not completely normal, with reduced long axis function and extensive but subtle changes on exercise. Patients are likely to be older women with a history of hypertension. Other cardiovascular risk factors, such as diabetes mellitus, atrial fibrillation and coronary artery disease are prevalent in the HFpEF population.

Identifying patients at risk of sudden arrhythmic death

24 Oct 2012Paid-up subscribers

Most GPs will encounter at least one case of sudden arrhythmic death syndrome (SADS) during their career. They may have to evaluate a young person at risk of SADS or offer support and screening to family members. GPs are usually the first point of call for families who have experienced the loss of a young relative. In England alone, SADS is responsible for 544 deaths per year. A significant proportion of cases may be preventable. First-degree relatives should be referred to an expert cardiac centre for comprehensive evaluation to identify individuals at risk.

 

Neurology

Rapid diagnosis vital in thunderclap headache

25 Apr 2016Registered users

Thunderclap headache is a severe and acute headache that reaches maximum intensity in under one minute and lasts for more than five minutes. Thunderclap headaches may be associated with symptoms such as photophobia, nausea, vomiting, neck pain, focal neurological symptoms or loss of consciousness. Subarachnoid haemorrhage (SAH) accounts for 10-25% of all thunderclap headaches and, despite advances in medical technology, has a 90-day mortality of 30%. Up to a quarter of cases of SAH are misdiagnosed, often through failure to follow guidance.

 

Seizure classification key to epilepsy management

24 Sep 2015Registered users

The diagnosis of epilepsy is often incorrect, potentially in up to 20% of cases, so should be revisited if seizures are not responding to treatment. SIGN recommends that the diagnosis of epilepsy should be made by an epilepsy specialist, ideally in the setting of a dedicated first seizure or epilepsy clinic. Diagnosis relies primarily on the history. Distinguishing between a genetic generalised epilepsy and a focal epilepsy is vital as this influences investigation, treatment and prognosis.

 

CPD exercises associated with each issue

CPD exercise - July/August 2016

01 Aug 2016Paid-up subscribers

All articles in The Practitioner online now include fillable PDF frameworks for personal reflection on learning and 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 detection of coeliac disease • Diagnosis and treatment of inflammatory bowel disease • Have a high index of suspicion for meningitis in adults • Identifying patients with complex PTSD

 

Women's health

Managing debilitating menopausal symptoms

21 Mar 2016Registered users

Severity and duration of menopausal symptoms varies markedly. Eight out of ten women experience symptoms and on average these last four years, with one in ten women experiencing symptoms for up to 12 years. Menopausal symptoms can begin years before menstruation ceases. A recent study found that women whose vasomotor symptoms started before the menopause suffered longest, median 11.8 years. Women whose hot flushes and night sweats started after the menopause had symptoms for a median of 3.4 years.

Underestimating risk in women delays diagnosis of CVD

21 Mar 2016Registered users

CVD remains the most common cause of mortality in women. There has been an increase in the prevalence of MI in women aged 35 to 54, while a decline in prevalence was observed in age-matched men. Although men and women share classic cardiovascular risk factors the relative importance of each risk factor may be gender specific. The impact of smoking is greater in women than men, especially in those under 50. Diabetes is a more potent risk factor for fatal CHD in women than men.

 

Mens' health

The role of PSA in detection and management of prostate cancer

25 Apr 2016Paid-up subscribers

The prostate specific antigen (PSA) test clearly provides the opportunity for clinically relevant prostate cancer to be detected at a stage when treatment options are greater and outcomes may be improved. In addition, a raised PSA may often indicate benign prostatic enlargement, and this may provide an opportunity for treatment of this condition before complications develop. However, in some patients the PSA test may lead to investigations which can identify clinically insignificant cancers which would not have become evident in a man’s lifetime.

Careful assessment key in managing prostatitis

23 Apr 2015

Prostatitis is a common condition estimated to affect up to 30% of men in their lifetime, it is most prevalent in men aged between 35 and 50. Prostatitis is subclassified into: acute bacterial prostatitis, chronic bacterial prostatitis, chronic pelvic pain and asymptomatic inflammatory prostatitis. Clinical assessment includes a thorough history and examination. A digital rectal examination should be performed after a midstream urine sample has been collected for urine dipstick, microscopy and culture. The prostate should be checked for nodules.

 

Renal medicine

Managing acute and chronic renal stone disease

22 Feb 2016Paid-up subscribers

The incidence of renal stone disease is increasing globally. In the UK the lifetime risk is estimated to be 8-10%. On a population level, the increase in stone incidence, erosion of gender disparity, and younger age of onset is likely to reflect increasing prevalence of obesity and a Western diet with a high intake of animal protein and salt.

Optimising the management of polycystic kidney disease

22 Feb 2016Registered users

Polycystic kidney disease is the most common inherited renal disorder that results in chronic kidney disease. Clinical features include visible haematuria, loin pain, UTI and hypertension. The typical clinical course is a progressive increase in the number and size of renal cysts associated with gradual loss of kidney function (falling eGFR).

 

Paediatrics

Optimising the management of wheeze in preschool children

23 Jun 2016

One third of all preschool children will have an episode of wheeze and many of these present to primary care. Most will fall within a spectrum of diagnosis ranging from episodic viral wheeze to multiple trigger wheeze or early onset asthma. The child should be referred to hospital immediately if you suspect an inhaled foreign body or anaphylaxis (after administering IM adrenaline). NICE recommends immediate referral for children with wheeze and high-risk features and also those with intermediate-risk features failing to respond to bronchodilator therapy.

Careful assessment the key to diagnosing adolescent heel pain

23 May 2016Registered users

The most common cause of adolescent heel pain is calcaneal apophysitis also known as Sever’s disease. Sever’s disease, Osgood Schlatter’s disease (tibial tuberosity) and Sinding-Larsen Johansson syndrome (distal patella) are all overuse syndromes brought about by repetitive submaximal loading and microtrauma. They are, however, entirely self-limiting and resolve at skeletal maturity or earlier. Careful assessment is required to differentiate them from other rare pathologies.

 

Editorials

Abrupt smoking cessation more effective than cutting down

23 Sep 2016Registered users

 A large trial to test whether or not an initial gradual reduction in smoking results in non-inferior quit rates compared with abrupt cessation across 31 general practices in England has reported.  The authors found clear evidence that quitting abruptly was superior in both the short- and longer-term over gradual cessation, and conclude that in clinical practice patients should be encouraged to stop smoking abruptly and not gradually.

 

Care of the elderly

Anxiety in older adults often goes undiagnosed

25 Jan 2016

Anxiety disorder in the elderly is twice as common as dementia and four to six times more common than major depression. Anxiety is associated with poorer quality of life, significant distress and contributes to the onset of disability. Mortality risks are also increased, through physical causes, especially cardiovascular disease, and suicide. Diagnosing anxiety disorders in older adults remains a challenge because of the significant overlap in symptoms between physical disorders and depression.

 

 

Controlling joint pain in older people

25 Jan 2016

The prevalence of chronic pain in older people in the community ranges from 25 to 76% and for those in residential care, it is even higher at 83 to 93%. The most common sites affected are the back, hip, or knee, and other joints. There is increased reporting of pain in women (79%) compared with men (53%). Common conditions include osteoarthritis and, to a lesser extent, the inflammatory arthropathies such as rheumatoid arthritis. The differential diagnosis includes non-articular pain such as vascular limb pain and nocturnal cramp, some neuropathic pain conditions (such as compressive neuropathies and postherpetic neuralgia), soft tissue disorders such as fibromyalgia and myofascial pain syndromes. 

Diagnosis and management of osteoporosis

22 Dec 2015

Osteoporosis is a common condition characterised by low bone mineral density and an increased risk of fragility fractures. It affects up to 30% of women and 12% of men at some point in their lives. The diagnosis of osteoporosis can be confirmed by DEXA but this should only be performed in patients who have an increased risk of fracture on the basis of clinical risk factors. DEXA should be considered if the 10-year risk of major osteoporotic fracture is > 10%.

 

Diagnosis and management of postherpetic neuralgia

22 Jan 2015Registered users

Risk factors for postherpetic neuralgia (PHN) include: increasing age; a prodrome of pain before rash onset; the degree of spread of the rash, particularly if it extends beyond a single dermatome; and severity of pain during the acute attack. Forty per cent of patients over 50 and 75% of those over 75 develop PHN following resolution of the rash. Patients with severe pain or those whose condition is affecting their daily activities and function should be referred to a specialist in pain management.

Establishing the cause of memory loss in older people

22 Jan 2015Registered users

Common causes of memory loss in older people are mild cognitive impairment, the various types of dementia, and psychiatric illness, mainly depression. Around 10% of patients with mild cognitive impairment progress to dementia each year. NICE guidance suggests examination of: attention, concentration, short- and long-term memory, praxis, language and executive function.

 

Dermatology

Tailor systemic therapy to the patient with severe psoriasis

22 Feb 2016Paid-up subscribers

There is no standard definition regarding the severity of psoriasis, and a number of factors should be considered, including the extent and stability of skin disease, involvement of joints, response to treatment, and impact on quality of life. Erythrodermic psoriasis and pustular psoriasis are severe conditions and the patient may be systemically unwell and febrile.

Diagnosis directs treatment in fungal infections of the skin

21 Oct 2015Registered users

Dermatophyte fungi are confined to the keratin layer of the epidermis and include three genera: Microsporum, Epidermophyton and Trichophyton. These infections can be transmitted by human contact (anthropophilic), from the soil (geophilic) and by animal (zoophilic) spread. Dermatophyte infections usually present as an erythematous, scaly eruption, which may or may not be itchy. Asymmetry is an important clinical clue to fungal infection, as is annular morphology.

Improving detection of non-melanoma skin cancer

05 Aug 2015

Basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) are clinically and pathologically distinct and both are locally invasive. However, while BCCs rarely metastasise, SCCs have the potential to do so especially when they arise on the ears or lips. Patients with one non-melanoma skin cancer (NMSC) have a higher risk of developing another NMSC and of malignant melanoma.

Managing urticaria in primary care

23 Feb 2015Paid-up subscribers

Urticaria is characterised by transient wheals that consist of a swollen palpable centre often surrounded by an erythematous flare, associated with itching or, less commonly, a burning sensation. Individual wheals usually disappear within 1 to 24 hours leaving normal skin. The prognosis for eventual recovery from spontaneous and inducible urticaria is excellent. However, the time course is unpredictable and may extend to years, often following a relapsing and remitting course.

Improving the management of rosacea in primary care

23 Oct 2014Registered users

Rosacea is more common in women than men and occurs more frequently in fair-skinned individuals, usually in the middle years of life. It tends to localise to the cheeks, forehead, chin and nose, sometimes showing marked asymmetry. Only very occasionally does it involve areas other than the face. Important distinguishing features from acne are a lack of comedones, absence of involvement of extra-facial areas, and the presence of flushing. Rosacea is a disfiguring condition that can have a major psychosocial impact, and its detrimental effect on emotional health and quality of life is often overlooked.

Identifying the causes of contact dermatitis

23 Jun 2014Paid-up subscribers

Contact dermatitis results from skin contact with an exogenous substance. It can be caused by direct contact, airborne particles, vapours or light. Individuals of any age can be affected. The two most common variants are irritant contact dermatitis (ICD) and allergic contact dermatitis (ACD). ICD is more common and has a worse prognosis. ICD is a form of eczema and is induced by direct inflammatory pathways without prior sensitisation. If eczema is recurrent/persistent, or occurs in an individual with no previous history of eczema, contact dermatitis should be considered. If ACD is suspected the patient should be referred to secondary care for patch testing.

Improving the management of seborrhoeic dermatitis

24 Feb 2014Paid-up subscribers

Seborrhoeic dermatitis usually starts at puberty with a peak incidence at 40 years of age and is more common in males. Patients develop symmetrical, well demarcated, dull or yellowish red patches and plaques with overlying adherent, yellowish greasy scales. Seborrhoeic dermatitis has a distinctive distribution in areas rich in sebaceous glands. Patients presenting with sudden onset severe seborrhoeic dermatitis should be screened for risk factors for HIV.

Intense nocturnal itching should raise suspicion of scabies

23 May 2013Paid-up subscribers

Scabies is spread by a mite transferring to the skin surface of an unaffected person, usually by skin to skin contact with an infested person, but occasionally via contaminated bed linen, clothes or towels. Patients with classical scabies usually present with an itchy non-specific rash. Often, the history alone can be virtually diagnostic. An intense itch, affecting all body regions except the head, typically worse at night, appearing to be out of proportion to the physical evidence, with a close contact also itching, should prompt serious consideration of scabies. The crusted variant of scabies may not be itchy. It is characterised by areas of dry, scaly, hyperkeratotic and crusted skin, particularly on the extremities.

Improving outcomes in patients with psoriasis

24 Jan 2013Paid-up subscribers

The majority of patients with psoriasis can be managed in primary care, although specialist care may be necessary at some point in up to 60% of cases. Patients with erythrodermic or generalised pustular psoriasis should be referred for a same day dermatological opinion, and if psoriatic arthritis is suspected, early referral for a rheumatological opinion is recommended. Recent guidance from NICE and SIGN will contribute significantly to the care of psoriasis sufferers in both primary and secondary care. [With external links to the evidence base]

Be vigilant for scurvy in high-risk groups

24 Oct 2012Paid-up subscribers

Scurvy is a disabling, potentially fatal, but entirely treatable, condition that can easily pass unrecognised. It has by no means been confined to the history books, even in affluent cultures, and vitamin C deficiency appears to be relatively common in the UK, particularly in those living on a low income. The occurrence of a macular purpuric eruption on the legs should always prompt consideration of the diagnosis of scurvy, especially in those at risk.

Improving the management of atopic eczema in primary care

25 Apr 2012Paid-up subscribers

Although generally considered a childhood ailment, 38% of patients with atopic eczema in the UK are adults. The condition often has a significant detrimental effect on the quality of life of affected individuals and their families. Despite national evidence-based guidelines in the UK, standards of care in the community setting can vary. Patients or carers should receive a full explanation of how to use topical treatments and a demonstration of how to apply dressings, if applicable. [With external links to the evidence base]

 

PHOTOGUIDE

Sun damage

23 Jun 2016Registered users

 • Squamous cell carcinoma • Actinic keratosis horn • Bowen’s disease • Solar elastosis • Rosacea • Discoid lupus

Conditions affecting the hair and scalp

25 Apr 2016Registered users

• Dermatitis artefacta • Alopecia mucinosa • Lichen planopilaris • Discoid lupus erythematosus • Sebaceous naevus • Basal cell carcinoma

 

HASLAM's view

Treat all your patients like VIPs

01 Aug 2016Registered users

... That taught me a lesson. From that moment on, I tried to treat everybody equally. Either no-one should be treated as a VIP, or everyone should. I felt embarrassed at how rapidly I had been seduced into treating someone differently simply because of who they were. If you think a patient is a VIP, treat them just the same as everyone else. Treat all your patients like VIPs.