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The Practitioner

The Practitioner contributes to the formal clinical literature and is primarily aimed at GPs, with subscribers throughout the World. All articles in The Practitioner online include CPD 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 articles

Detailed history the cornerstone of epilepsy diagnosis

24 Sep 2020

The incidence of epilepsy in the UK is estimated to be 50 per 100,000 per year and up to 1% of the population have active epilepsy. The diagnosis of epilepsy will usually be made in a neurology clinic. A generalised seizure as part of a generalised epilepsy syndrome may occur without warning but may be preceded by blank spells or myoclonic jerks. A generalised seizure with focal onset may be preceded by an aura. Brain imaging is required in almost all cases where epilepsy is suspected, the only possible exception being people with generalised epilepsies proven on EEG. MRI is the imaging modality of choice.

GPs should be vigilant for acute deterioration in myasthenia gravis

24 Sep 2020Registered users

Myasthenia gravis is an autoimmune disorder of neuromuscular junction transmission. It is relatively rare, with an approximate annual incidence of 1 per 100,000 population, and prevalence of 15 per 100,000 population in the UK. An ocular presentation may include fatiguing ptosis or diplopia. Typically, symptoms ‘fatigue’ (the physical power of the muscle deteriorates rapidly with repeated activity) and become more noticeable as the day progresses. More generalised symptoms include fatiguing difficulty with speech or swallowing. There may be fatiguing weakness of the arms and legs. The diagnosis will usually be confirmed by referral to a neurologist. 

 

Special reports

Optimising the management of diverticular disease

24 Sep 2020Registered users

Diverticular disease is characterised by intermittent abdominal pain in the left lower quadrant of the abdomen associated with constipation or diarrhoea. It can be difficult to differentiate from other conditions such as colitis, irritable bowel syndrome and colorectal cancer. Acute diverticulitis typically presents with severe constant left lower quadrant pain associated with signs of systemic upset such as fever. The patient may also have a change in bowel habit or rectal bleeding. On examination there is tenderness in the left lower quadrant. Acute diverticulitis may be complicated by perforation, abscess, fistula formation, bleeding or a stricture.

Optimising the management of depression in children

24 Jul 2020Registered users

In a large meta-analysis, the prevalence of depression was twice as common in adolescents (5.7%) than children (2.8%). The 2:1 female to male ratio of depression seen in adults becomes apparent from the age of 12 years. Three quarters of children aged 3-17 years with depression also have anxiety, and almost half have associated behaviour problems. Depression should be treated by child and adolescent mental health services unless the episode is mild and of < 2-3 months’ duration.

 

Women's health -Temporary direct access

Investigating the cause of heavy menstrual bleeding

25 Mar 2019

Heavy menstrual bleeding has been defined as ‘excessive menstrual blood loss which interferes with a woman’s physical, social, emotional, and/or material quality of life’. Heavy menstrual bleeding affects 25% of women of reproductive age and is estimated to be the fourth most common reason for gynaecological referrals. Women should be asked about pelvic pain which might suggest endometriosis and pressure symptoms which might suggest significant fibroids. Examination is appropriate if there is intermenstrual or postcoital bleeding and, if the woman is actively bleeding, may identify the source of the bleeding.

Symptom recognition key to diagnosing endometriosis

22 Mar 2018

Endometriosis affects around one in ten women of reproductive age in the UK. NICE guidance highlights the importance of symptoms in its diagnosis. A normal abdominal or pelvic examination, ultrasound, or MRI should not exclude the diagnosis. Endometriosis should be suspected in women and adolescents who present with one or more of: chronic pelvic pain, significant dysmenorrhoea, deep dyspareunia, period-related or cyclical GI or urinary symptoms, or infertility. If endometriosis is suspected or symptoms persist, patients should be referred for further assessment.

 

Psychiatry

GPs have a pivotal role in bipolar disorder

25 May 2020Paid-up subscribers

Bipolar disorder is a complex, recurrent, severe and potentially lifelong mental illness. The peak age of onset is 15-19 years, with most cases developing before the age of 30. It is crucial to distinguish bipolar from unipolar depression not only as an essential starting point for appropriate treatment and risk management, but also to avoid antidepressant monotherapy which can exacerbate the frequency and severity of mood symptoms and cause resistance to appropriate medications.

Treating psychological trauma in the real world

23 Jan 2020Paid-up subscribers

After a potentially traumatic event (PTE), many individuals experience either no distress or only transient distress, while others suffer considerable morbidity and may develop post-traumatic stress disorder (PTSD). Around one-third of people experiencing a PTE will develop PTSD, though this varies depending on the type of traumatic event and rates of PTSD are higher with type 2 trauma. Type 2 trauma involves repeated traumatic experiences over extended periods. Although PTSD symptoms can be present acutely, the diagnosis requires the persistence of symptoms for at least one month and the symptoms should cause functional impairment.

Early intervention key in first episode psychosis

20 Dec 2019Paid-up subscribers

Psychosis is a state of mind in which a person loses contact with reality in at least one important respect while not intoxicated with, or withdrawing from, alcohol or drugs, and while not affected by an acute physical illness that better accounts for the symptoms. Common positive symptoms of psychosis include delusions and hallucinations. These symptoms are strongly influenced by the underlying cause of the psychosis: delusions in schizophrenia tend to be bizarre; delusions in depression negative; delusions in mania expansive. When a patient presents with psychotic symptoms, it is important to take a full psychiatric history, perform a mental state examination and complete relevant investigations, as indicated in each individual case.

GPs are central to improving care of schizophrenia patients

20 Dec 2019Paid-up subscribers

Schizophrenia often runs a chronic course and is associated with considerable morbidity and mortality. While psychotic symptoms are the most obvious manifestations of the condition, negative symptoms (e.g. apathy and withdrawal) and cognitive symptoms (especially deficits in executive function) are often more disabling. It generally presents in late adolescence or early adulthood. Schizophrenia typically develops insidiously, potentially over several years. The GP is ideally placed to respond to family concerns, identify prodromal symptoms, screen for psychotic symptoms and initiate either a mental health review or active monitoring in primary care.

 

Paediatrics

Prompt treatment of impetigo reduces risk of spread

22 Jun 2020Paid-up subscribers

Impetigo is a common contagious bacterial infection of the skin. The causative organisms are either Staphylococcus aureus or, less commonly, Streptococcus pyogenes. The infection can occur at any age, but it is particularly common in children, especially the pre-school and early school age years, and tends to be more frequent during the summer months. It may arise on previously normal skin or complicate a pre-existing dermatosis. The diagnosis is essentially a clinical one, but if in doubt a swab should be taken for bacteriological culture.

Improving the detection and management of peanut allergy

25 May 2020Registered users

Peanut allergy currently affects around 2% of the population. It is the most common cause of fatal food related anaphylaxis. Most patients (80%) will have long-lived peanut allergy. Primary peanut allergy most commonly presents in the first 5 years of life after the first known exposure to peanut. Clinical features are those of an IgE-mediated reaction. All patients with a history suggestive of peanut allergy should be referred to an allergy clinic for comprehensive assessment and management.

Early recognition key in child and adolescent anxiety disorders

23 Apr 2020Registered users

Anxiety disorders are common, highly treatable conditions, with a strong evidence base for cognitive behaviour therapy. In a recent population sample of the under 12s, only 65% of those who met criteria for a diagnosis of an anxiety disorder had sought professional help and only 3.4% had received an evidence-based treatment. Assessment should include an exploration of neurodevelopmental conditions, drug and alcohol misuse, and speech and language problems.

Improving outcomes in allergic rhinitis in children

24 Jun 2019Paid-up subscribers

Allergic rhinitis can affect a child’s physical health, reduce their quality of life, sleep and concentration, and impact on school performance. Children with allergic rhinitis are at increased risk of developing asthma. Around 85% of those with asthma have allergic rhinitis, which can complicate diagnosis and management and also increase the risk of hospitalisation for asthma exacerbations. However, appropriate management of allergic rhinitis can improve asthma control. The diagnosis of allergic rhinitis can usually be made on the basis of the patient’s history and examination alone. 

 

Editorials

Delirium linked to cognitive decline

24 Sep 2020

Delirium is associated with an increased risk of subsequent cognitive decline and there is evidence to suggest that the association is causal, a systematic review and meta-analysis has found. Every study found that those with delirium experienced greater cognitive decline than controls and the combined odds for a given cognitive decline were more than doubled in patients with delirium; OR 2.30. Subgroup analyses provided evidence that delirium is a causative factor rather than a marker of vulnerability to dementia.

 

Research reviews - by GPs with a special interest

Nausea may affect adherence to varenicline

24 Sep 2020Registered users

Nausea during the first few weeks of varenicline therapy may reduce adherence, a study from North America has found. The authors analysed data on 870 adults receiving varenicline in two smoking cessation trials conducted at multiple sites in Canada and the USA.

Is air pollution associated with onset of asthma in childhood?

24 Sep 2020Registered users

A nationwide case-control study from Denmark has strengthened the evidence that parental asthma and smoking in pregnancy are risk factors for onset of asthma and persistent wheezing in children. The results also suggest that exposure to ambient small particles < 2.5 µm (PM2.5) may be a potential risk factor. However, this finding needs to be substantiated in future studies, the authors say.

 

HASLAM's view

If symptoms persist …

24 Sep 2020Registered users

Reassurance is a mighty tricky skill. Get it right, and your patient will be happy, and unnecessary investigations and prescriptions will be avoided. Get it wrong, and the consequences can be profound. Over my career I developed a very simple rule. It’s fine to reassure a patient once. Be very cautious about giving reassurance twice. Never, ever, give reassurance three times.

 

Cancer - Open access

Optimising the management of early prostate cancer

23 Apr 2020

Men born after 1960 in the UK now have a 1 in 6 estimated lifetime risk of being diagnosed with prostate cancer. NICE recommends that men over 50 years old who request a PSA test should be fully counselled about the test beforehand. The test should also be offered to men with LUTS or an abnormal DRE. If the prostate feels malignant on DRE this should trigger a fast track referral to secondary care, via a suspected cancer pathway referral, even if the PSA is normal. Men with PSA values above the age-specific reference range should also be referred to urology urgently, via a suspected cancer pathway referral.

Time to diagnosis key in improving lung cancer outcomes

25 Nov 2019

NICE recommends urgent referral via a suspected cancer referral pathway to the two week wait service if: chest X-ray findings suggest lung cancer or if patients aged 40 and over have unexplained haemoptysis. However, studies have indicated that around 20-25% of patients with confirmed lung cancer may have a chest X-ray reported as normal and this figure may be higher for early stage lung cancers. Therefore, the National Optimal Lung Cancer Pathway recommends that where there is a high suspicion of underlying malignancy (but the chest X-ray is normal), GPs should refer patients directly for a CT scan.

 

A hundred and fifty years ago

150 years ago:Temporary loss of vision in scarlet fever

24 Sep 2020Registered users

Louisa M., aged 17 years, and living as servant in a gentleman’s family, at Wandsworth, where the mistress and a young child  had died from scarlatina, fell ill with the same complaint on December 27th, 1869. All were treated homoeopathically by the family attendant, and one week from commencement of fever Louisa M. was ordered out of bed, and, four days later, requested to take outdoor exercise. January 24th Awoke at 3 a.m. with violent fit of vomiting in the midst of which the sight of both eyes was entirely lost; nothing abnormal in external appearance of eye, except that the conjunctiva was congested; the pupils were slightly dilated, but acted well. Applied mustard poultices to nape of neck and behind both ears, applied blisters to both temples and slightly darkened the room.

 

A hundred years ago

100 years ago: Raised blood pressure well borne

24 Sep 2020Registered users

Let me quote a case which I take to be one of an habitual high range of arterial pressure very well borne, but upon which any accession of tension is hazardous. A gentleman of splendid physique, aged 74, height 6 ft 3 in, weight 17 stone, of calm temperament, a soldier and a sportsman in the past, has been under my observation for some fifteen years. His average health has been excellent. He has presented slight gouty symptoms from time to time, but the kidneys are healthy. He suffers occasional giddiness when walking or turning quickly in bed. There  is some naso-pharyngeal catarrh which is liable to extend to the larger bronchial tubes. For the past eight years his blood pressure has been observed to be high; 180, 200, 170 and 160 as the lowest maximum with diastolic 90-100. The pulse ranges 72-80.The vessels are good, the gums are sound.