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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

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.

 

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.

 

Special reports

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.

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.

 

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.

 

PHOTOGUIDE

Sun damage 2016

23 Jun 2016Registered users

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

 

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.

Have a high index of suspicion for atrial fibrillation

23 Oct 2014Registered users

The lifetime risk of atrial fibrillation (AF) for men and women over the age of 40 is about 25%. The condition affects around 800,000 people in the UK, of which it is estimated that 250,000 are undiagnosed. A rapid heart rate may result in palpitations, dyspnoea or chest tightness, whereas loss of atrial contractility may lead to fatigue and reduced exercise capacity. In patients with a confirmed diagnosis of AF, three areas need to be considered: stroke risk, symptoms, and risk of tachycardia cardiomyopathy.

 

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.

 

Dermatology

Managing patients with hidradenitis suppurativa

23 May 2016Paid-up subscribers

Hidradenitis suppurativa affects the apocrine-bearing areas of the skin. The onset is variable but usually occurs in the second and third decades of life, coinciding with development of the apocrine glands. The condition is characterised by painful, inflammatory papules and nodules which frequently progress to form abscesses, sinus tracts and hypertrophic scars.The most important non-genetic factors implicated in hidradenitis suppurativa are obesity and smoking.

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.

 

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

Chlamydia infection raises long-term risk of reproductive complications

01 Aug 2016Paid-up subscribers

Infection with chlamydia increases the risk of pelvic inflammatory disease (PID), ectopic pregnancy and tubal factor infertility by at least 30%, a nationwide study from Denmark has shown. The risk persisted throughout the 17 years of follow-up. Following a second infection the risk of PID was increased by a further 20%. Adjusted hazard ratio for each reproductive complication was 31-50% higher in women who tested positive for chlamydia compared with women who tested negative.

 

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.

 

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).