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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

Thorough assessment key to management of varicocele

22 Apr 2021Registered users

Varicoceles are usually asymptomatic but some patients may present with a scrotal swelling or pain. The patient should be examined in both the standing and supine positions, with and without a Valsalva manoeuvre. Patients may also present with primary or secondary infertility, with a varicocele detected on clinical examination or by imaging. Men presenting with infertility should be assessed with a reproductive history, semen analysis and hormone profile, including testosterone, LH and FSH.

GPs should have a high index of suspicion for testicular cancer

22 Apr 2021

Most men with testicular cancer present with a lump that they have identified in their scrotum. Although the scrotal swelling is usually painless, pain is the first symptom in around 20% of patients, typically a dull or dragging ache in the testicle or a heaviness in the scrotum. NICE recommends that all men who have a non-painful enlargement or change in shape or texture of their testis should be referred urgently to urology using the two-week wait pathway. In men who have unexplained or persistent testicular symptoms, an urgent direct access testicular ultrasound scan should be requested. 

GPs have a key role in the management of miscarriage

22 Mar 2021Registered users

First trimester miscarriage affects up to one in four pregnancies. While some women will experience bleeding and pain, others have no symptoms and are given the diagnosis at their 12-13 week booking scan. In 50-85% of cases the cause is due to a spontaneous chromosomal abnormality, most commonly trisomy. Many women suffer from psychological sequelae including PTSD, anxiety and depression. GPs should offer a follow-up appointment to all women who have had a miscarriage to: discuss any questions the woman has regarding her miscarriage; assess the woman’s psychological wellbeing and offer counselling if appropriate.

Optimising the assessment and management of osteoporosis

22 Mar 2021Registered users

Osteoporosis affects around 40% of women and 13% of men at some point in their lives. While almost any bone can fracture as the result of osteoporosis, the most common sites are the wrist, spine, hip and humerus. The presence of one or more clinical risk factors in individuals aged 50 and over is an indication for a fracture risk assessment. There is a strong evidence base for drug treatment in DXA proven osteoporosis and those with low trauma vertebral fractures.

Reducing cardiovascular risk pivotal in diabetic kidney disease

21 Feb 2021Registered users

Diabetic kidney disease is associated with a very high risk of cardiovascular disease (CVD) and premature mortality from cardiovascular events. There is good evidence that multifactorial interventions that optimise BP, limit proteinuria and minimise cardiovascular risk can reduce morbidity and premature mortality. Early diabetic kidney disease is asymptomatic. Microalbuminuria, defined as a urinary ACR of 3-30 mg/mmol on two occasions three months apart is the earliest clinically detectable indicator of diabetic kidney disease. Excellent glycaemic control can delay onset of microalbuminuria.

 

Special reports

Improving early recognition and treatment of anaphylaxis

22 Apr 2021Registered users

Anaphylaxis is a serious potentially life-threatening systemic hypersensitivity characterised by airway, breathing and/or circulation compromise. Where feasible, any trigger should be removed. Hypotensive patients should be placed in a supine position with or without leg elevation but those with airway or breathing compromise may prefer to sit up. A standard adrenaline dose of 500 micrograms (0.5 ml of 1:1,000 adrenaline) is recommended in adults, whereas dosage varies in children depending on age/weight. 

Improving the detection and treatment of hepatitis C

22 Mar 2021Registered users

Many patients with chronic hepatitis C virus (HCV) infection remain unaware of their diagnosis until they present with decompensated chronic liver disease or hepatocellular carcinoma (HCC). Prolonged infection with HCV predicts increased risk of progression to cirrhosis and increased HCC risk. Consequently, all patients with a positive HCV RNA test should be considered for referral to specialist hepatology or infectious diseases services for prompt treatment and attempted cure.

Holistic approach needed to tackle chronic primary pain

21 Feb 2021Paid-up subscribers

The International Association for the Study of Pain has developed a new classification system for chronic pain. A fundamental distinction is made between chronic primary pain and chronic secondary pain. Chronic primary pain is defined as pain in one or more anatomical regions that persists for longer than three months, is associated with disability or emotional distress, not better accounted for by another diagnosis of chronic pain. Chronic primary pain is subdivided into five categories. Chronic secondary pain is pain secondary to an underlying disease.

Aetiology key to the management of bronchiectasis

25 Jan 2021Registered users

Bronchiectasis increases in incidence and prevalence with age affecting > 1% of people aged 70 and older. It is associated with significant morbidity and mortality. Bronchiectasis can be congenital or acquired following a lung-damaging event such as severe infection, or have an immunological aetiology, but the cause is not always found. It can be associated with inflammatory bowel disease, rheumatoid arthritis and other connective tissue diseases. Most patients with bronchiectasis present with persistent cough and daily sputum production. Bronchiectasis is diagnosed using high resolution CT.

Psoriatic arthritis often goes unrecognised

21 Dec 2020Registered users

Psoriatic arthritis (PsA) is a seronegative systemic disease that belongs to the family of spondyloarthropathies. Its worldwide prevalence ranges from 0.05% to 1%, and it appears in 10-40% of patients with skin psoriasis; however, it is believed to be underdiagnosed. More than 80% of patients who are diagnosed with PsA already have skin disease, mainly in the form of plaque psoriasis. However, 15% of patients present with musculoskeletal involvement prior to psoriasis which makes the diagnosis of PsA challenging. It is important to do a thorough clinical assessment, take a family history and actively look for evidence of psoriasis: this includes examining nails, the scalp, intergluteal region and umbilicus.

Early symptom recognition key in management of TIA and stroke

24 Nov 2020Registered users

In the UK, at least 100,000 people have an acute stroke each year. A first ever transient ischaemic attack (TIA) affects around 50 people per 100,000 per year and around 15% of people who have a first stroke have had a preceding TIA. Patients with a suspected TIA should be referred immediately for specialist assessment and investigation, to be seen within 24 hours of onset of symptoms. Patients with a suspected stroke should be admitted immediately to hospital, ideally to an acute stroke unit. Patients with a suspected TIA who have a bleeding disorder or are taking an anticoagulant should also be admitted to an acute stroke unit as haemorrhage must be excluded.

 

Women's health

Tailor treatment to the patient in polycystic ovary syndrome

24 Mar 2020Registered users

Polycystic ovary syndrome is a condition characterised by hyperandrogenism, multifollicular ovaries and ovulatory dysfunction. It affects 8-13% of women of reproductive age and is associated with insulin resistance, hyperlipidaemia and obesity. Baseline measurements should include blood pressure and BMI. Clinical signs of hyperandrogenism including hirsutism, acne and androgenic alopecia should be assessed. A hormone profile should be done during days 1-5 of the menstrual cycle or as a random sample when there is amenorrhoea.

Investigating the cause of heavy menstrual bleeding

25 Mar 2019Registered users

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 2018Registered users

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.

 

Gastroenterology

Early treatment can arrest or reverse cirrhosis

24 Jul 2020Paid-up subscribers

Around 60,000 people in the UK are estimated to have cirrhosis. It is now the third most common cause of premature death. Decompensation represents a watershed moment for patients with cirrhosis, with the median survival falling from > 12 years for compensated cirrhosis to approximately two years. Patients with cirrhosis should undergo six-monthly ultrasound to screen for the early development of primary hepatocellular carcinoma. They should also undergo an initial upper gastrointestinal endoscopy to screen for varices.

Tailor treatment to the patient with gallstone disease

24 Jul 2020Paid-up subscribers

Gallstones affect around 15% of adults in the UK. Between 50 and 70% of patients with gallstones are asymptomatic at diagnosis and only 10-25% of these individuals will go on to develop symptomatic gallstone disease. The vast majority (90-95%) of gallstones are cholesterol stones. Obesity is associated with an increased risk of symptomatic gallstones. Patients with symptoms suggestive of gallstones should be offered liver function tests and an abdominal ultrasound.

Early detection of liver cancer key to improving outcomes

07 Aug 2019

Hepatocellular carcinoma (HCC) accounts for around 90% of liver cancer cases and intrahepatic cholangiocarcinoma (CC) for 9-10%. Most cases of HCC occur in the context of chronic liver disease with cirrhosis, particularly in those with chronic hepatitis B or C. Other major risk factors include excessive alcohol consumption, obesity and aflatoxins. Overall, 10-15% of cirrhotic patients will develop HCC within 20 years. Patients presenting with an upper abdominal mass consistent with an enlarged liver should be referred for an urgent direct access ultrasound scan within two weeks. 

Optimising the treatment of inflammatory bowel disease

07 Aug 2019Paid-up subscribers

Inflammatory bowel disease (IBD) is a chronic inflammatory condition which runs a relapsing and remitting course. Ulcerative colitis (UC) is more common than Crohn’s disease (CD). UC almost always affects the rectum and extends proximally and continuously to the colon to a variable extent. CD most commonly affects the terminal ileum or colon but can affect any part of the gastrointestinal tract from the mouth to the anus. The vast majority (90%) of people with UC report bloody stools compared with less than 50% of those with CD. CD is characterised by a triad of abdominal pain, diarrhoea and weight loss.

Improving outcomes in pancreatic cancer

25 Jul 2018

The combination of an aggressive disease, vague presenting symptoms and insensitive standard diagnostic tests is a key factor contributing to poor outcomes with only 15% of patients with pancreatic cancer having operable disease at diagnosis. The NICE guideline on referral for suspected cancer recommends urgent referral via a suspected cancer pathway referral if the patient is aged 40 and over with jaundice. It also recommends that an urgent direct access computerised tomography (CT) scan referral should be considered in patients aged 60 and over with weight loss and any of the following: diarrhoea; back pain; abdominal pain; nausea; vomiting; constipation; new onset diabetes. Pancreatic cancer requires a CT scan for diagnosis.

 

Psychiatry

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.

Treating psychological trauma in the real world

23 Jan 2020

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 2019

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.

 

Allergy

Improving early recognition and treatment of anaphylaxis

22 Apr 2021Registered users

Anaphylaxis is a serious potentially life-threatening systemic hypersensitivity characterised by airway, breathing and/or circulation compromise. Where feasible, any trigger should be removed. Hypotensive patients should be placed in a supine position with or without leg elevation but those with airway or breathing compromise may prefer to sit up. A standard adrenaline dose of 500 micrograms (0.5 ml of 1:1,000 adrenaline) is recommended in adults, whereas dosage varies in children depending on age/weight. 

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.

 

Editorials

Two out of three smokers consulting their GP do not receive smoking cessation support

22 Apr 2021Registered users

Just under half of smokers in England who reported visiting their GP in the past year recalled receiving advice on smoking cessation, and only one in three were offered support to quit, a national survey has found. However, current clinical guidelines suggest GPs should use every opportunity to ask patients about smoking and advise and encourage every smoker to stop. There is good evidence that brief advice from a GP helps smokers to quit.

What is the role of the Edinburgh Postnatal Depression Scale?

22 Mar 2021Registered users

The optimal cut-off score of the Edinburgh Postnatal Depression Scale is 11, a systematic review and meta-analysis has found. However 7-8 women out of 10 with a positive screen will not have major depression.

Loneliness a potential risk factor for depression

21 Feb 2021Registered users

Loneliness is associated with an increased risk of developing depression, a longitudinal cohort study has found. The English Longitudinal Study of Ageing (ELSA) recruited 11,391 participants aged 50 years and over who were living in a private household in 2002. Participants were followed up every two years until 2016/17.

 

HASLAM's view

Times change but patients remain essentially the same

22 Apr 2021Registered users

My very first column for The Practitioner, back in 1996, focused on perceptions of risk, something that is every bit as relevant today. However fast the times may change patients change remarkably little.

Facing up to difficult situations

22 Mar 2021Registered users

Zoom can be extraordinarily time saving, cutting out all that travel involved in getting to meetings, and giving a genuine and important environmental benefit, but it cannot replace the less tangible aspects of human interaction.

 

Research reviews - by GPs with a special interest

Do oral steroids improve respiratory outcomes in preschool children with acute wheeze?

22 Apr 2021Registered users

Oral prednisolone had little effect on respiratory parameters at 24 hours in young children attending an emergency department with acute wheeze, in a study from New Zealand. However, admission rates, and the need for additional oral prednisolone and intravenous medication were lower in children in the prednisolone group.

Recreational substance use raises risk of early onset CVD

22 Apr 2021Registered users

Use of illicit drugs, as well as tobacco and alcohol, is associated with an increased risk of premature atherosclerotic cardiovascular disease (CVD), especially in women, a study from the US has shown. Those with multiple substance use had a graded response with the highest risk of premature CVD among individuals who used four or more recreational substances.

Miscarriage associated with raised risk of premature death

22 Apr 2021Registered users

A history of one or more miscarriages appears to be associated with an increased risk of dying before the age of 70, an analysis of data from the US Nurses’ Health Study II has found. When the cause of death was examined, the strongest association was with cardiovascular disease.

Sex differences remain in the prevalence and treatment of CVD risk factors

22 Mar 2021Registered users

Differences persist in the prevalence, treatment and control of risk factors for cardiovascular disease between men and women, an analysis of data from the Health Survey for England 2012-2017 has found. Men were more likely to have one or more risk factors than women. However, figures for both treatment and control of dyslipidaemia were significantly lower in women than men.

 

A hundred and fifty years ago

150 years ago: Eye sequelae of small-pox

22 Mar 2021Registered users

Her brother, a seaman, had small-pox when he was four years of age; he had not been vaccinated. A brother-in-law had small-pox three months ago – i.e. at the same time as Rosina T. and died of it. He was said to have been ‘stone-blind’ three days before he died. .... The case illustrates well the protracted  nature of keratitis following small-pox; and the family history is extremely interesting as a proof of the danger of neglecting vaccination and of the protective qualities of the operation, should any further proof be wanting of so well-established a fact in therapeutics.

 

A hundred years ago

100 years ago: Neurasthenia and fear of impotence

22 Apr 2021Registered users

It is not rare to see a confirmed belief, or a vague dread of impotence develop in men who are about to marry. It may occur in those who have masturbated in early life, or who have been subject to frequent seminal emissions, or any form of previous venereal disease may give rise to it. The fear or idea at first worries, then depresses, and thus alone or combined, as it frequently is, with an undue exaggeration of the responsibilities of the step to be taken, may produce a definite neurasthenic state. In others, the dread of impotence leads to delusions of non-existent disease, and thus produces a state of hypochondria, from which a neurasthenia may develop later. It is these hypochondriacal cases – but the same may occur in neurasthenia that develops along the same lines – that become so depressed and feel so incapable of the duties they are about to undertake, that either commit suicide or abscond on the eve of marriage.

 

Cancer - Temporary direct access

GPs should have a high index of suspicion for testicular cancer

22 Apr 2021

Most men with testicular cancer present with a lump that they have identified in their scrotum. Although the scrotal swelling is usually painless, pain is the first symptom in around 20% of patients, typically a dull or dragging ache in the testicle or a heaviness in the scrotum. NICE recommends that all men who have a non-painful enlargement or change in shape or texture of their testis should be referred urgently to urology using the two-week wait pathway. In men who have unexplained or persistent testicular symptoms, an urgent direct access testicular ultrasound scan should be requested. 

Diagnosis and management of malignant pleural mesothelioma

21 Dec 2020

Mesothelioma accounts for less than 1% of all cancers in England, Wales and Northern Ireland. There are almost 2,500 new diagnoses a year, of which 96% are pleural. The median age at diagnosis for malignant pleural mesothelioma (MPM) is 76 years. The majority of cases occur in men, most commonly following occupational exposure to asbestos. There is a latent period, usually 30-40 years, between exposure and disease development. A chest X-ray is usually the first-line investigation; 94% of patients with MPM have a unilateral pleural effusion, although the chest X-ray may be normal or show another asbestos-related lung disease.