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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

Diagnosing mild cognitive impairment can prove challenging

25 May 2021Registered users

Mild cognitive impairment (MCI) is a heterogeneous clinical syndrome defined as evidence of cognitive decline which is greater than expected for an individual’s age and educational level but which does not significantly impact on activities of daily living. The challenge for clinicians is to distinguish between normal cognition, cognitive decline normal for ageing, subjective cognitive decline, delirium, MCI and dementia. The history should focus on the onset and progression of symptoms. An acute or fluctuating course suggests delirium or another potentially reversible cause.

Shared care central to management of substance use disorder

25 May 2021Registered users

Substance use disorder (SUD) encompasses the use of drugs (illicit and prescription) or alcohol in a way that may cause harm and is difficult to control. Diagnosis is based on clinical history and examination in accordance with ICD-11 criteria which categorise use as hazardous, harmful or dependent. People often see their GP for a medical problem arising from SUD without mentioning substance use. Good rapport and an empathetic attitude can facilitate disclosure. 

 

Special reports

Diagnosis and management of primary hyperparathyroidism

25 May 2021Registered users

Primary hyperparathyroidism (PHPT) most commonly occurs sporadically, typically caused by a parathyroid adenoma. Such cases are more common in women and with increasing age. Other risk factors include neck irradiation and lithium use. Inherited cases can occur in relation to genetic conditions including MEN1. Parathyroid carcinoma is vanishingly rare. PHPT may present with symptoms of hypercalcaemia (such as thirst, excessive urination or constipation), or evidence of potential end organ effects. However, the most common presentation is an incidental finding of a raised albumin-adjusted serum calcium.

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. 

 

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. 

 

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.

 

Musculoskeletal medicine

Treating to target will optimise long-term outcomes in RA

24 Nov 2020Paid-up subscribers

Rheumatoid arthritis (RA) classically causes a symmetrical, small joint polyarthritis which left untreated can lead to joint destruction and deformity. NICE recommends that any adult with suspected persistent synovitis of undetermined cause should be referred for a specialist opinion. Patients should be referred urgently (even with a normal acute-phase response, negative anti-CCP antibodies or rheumatoid factor) if any of the following apply: the small joints of the hands or feet are affected; > 1 joint is affected; there has been a delay of ≥ 3 months between onset of symptoms and seeking medical advice.

Diagnosis and management of Paget’s disease of bone

24 Nov 2020

Paget’s disease of bone is a metabolic disease in which focal abnormalities of bone remodelling occur in one or more skeletal sites. The affected bones enlarge and may become deformed and this can lead to complications including bone pain, pathological fractures, secondary osteoarthritis, deafness and nerve compression syndromes. The three main risk factors are age, male gender and family history. People with a first-degree relative with Paget’s disease have a seven-fold increased risk of developing the disease. Patients who have bone deformity or symptoms that might be due to Paget’s disease should be referred to secondary care. 

 

Neurology

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. 

 

Women's health

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.

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.

 

Care of the elderly

Diagnosis and management of age-related macular degeneration

25 Jan 2021Paid-up subscribers

Age-related macular degeneration (AMD) is a cause of painless, gradual loss of vision. Epidemiological evidence suggests 4-8% of people aged over 65 years in the UK have visually significant AMD. Patients with suspected neovascular AMD (NvAMD) should be seen by ophthalmology within two weeks, and if the diagnosis and progressive disease are confirmed, treatment should commence within the same timeframe. Intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents cause regression of neovascularisation and reduce macular oedema. There is no treatment for dry AMD.

Diagnosing anxiety disorders in older adults can be challenging

25 Jan 2021Paid-up subscribers

In older adults, the prevalence of anxiety disorders is higher among those with other health problems, and those in hospital and care settings. A primary depressive disorder should be excluded whenever an older person presents with anxiety symptoms for the first time, and comorbid anxiety often indicates a more severe presentation of depression. Around four in five patients have a comorbid physical disorder. Medical conditions can mimic symptoms of, predispose to, or even directly precipitate an anxiety disorder, and may colour its symptomatology or limit treatment options.

Elderly onset RA: a diagnostic and therapeutic challenge

23 Jan 2020Paid-up subscribers

Elderly onset rheumatoid arthritis (EORA) is defined as rheumatoid arthritis (RA) with age of first onset 65 years or over. It comprises an acute onset proximal or large joint arthritis with a prominent systemic syndrome characterised by constitutional symptoms and a higher ESR than in the younger patient with RA. Investigations should focus on trying to establish the cause and ruling out differential diagnoses. They should include inflammatory markers, serum uric acid, full blood count, rheumatoid factor/anti-CCP antibodies, and X-rays of the affected joint as well as the hands and feet. The possibility of malignancy should always be borne in mind. NICE recommends urgent referral of all suspected cases.

 

Editorials

Are antidepressants effective for back pain and osteoarthritis?

25 May 2021Registered users

Serotonin-noradrenaline reuptake inhibitors (SNRIs) reduce both pain and disability in patients with low back pain and osteoarthritis (OA). However, the effect is small and not clinically relevant for back pain, although a clinically important effect for OA cannot be ruled out, a systematic review and meta-analysis has concluded.

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.

 

HASLAM's view

Prevention success stories often go unheralded

25 May 2021Registered users

The current national vaccination programme for COVID-19 has been a remarkable success of historic proportions. Whether carried out at major district hubs or in small GP practices, the logistics, the organisation, the friendliness, and the positivity, are all attributes that everyone involved can be proud of. Many GP teams have found this work challenging but also incredibly heart warming.

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.

 

Research reviews - by GPs with a special interest

Raised NT-proBNP predicts poor outcomes in AF without heart failure

25 May 2021Registered users

High NT-proBNP levels appear to be an independent predictor of adverse outcomes in patients with atrial fibrillation (AF) in the absence of heart failure, a study from Japan has found. Raised NT-proBNP levels were significantly associated with higher incidences of stroke/systemic embolism, all-cause death and hospitalisation for heart failure during a median follow-up period of five years.

Preterm birth associated with raised risk of developmental problems at age five

25 May 2021Registered users

Rates of cerebral palsy and moderate and severe neurodevelopmental problems in five year olds were higher in children born prematurely compared with those born at full term, a large study from France has found.

Pattern of heavy drinking with bingeing linked to depression

25 May 2021Registered users

Patterns of alcohol consumption in particular frequent use plus frequent bingeing have positive associations with symptoms of depression such as depressed mood, poor appetite or overeating, feelings of worthlessness or guilt and psychomotor agitation or retardation, a German study has found.

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.

 

A hundred and fifty years ago

150 years ago: Paralysis as a result of alcoholic excess

25 May 2021Registered users

This was a very sad case; there can be no doubt that a naturally clever, well conducted, capable, I might say talented female, was utterly degraded and ruined by succumbing to the fatal craving for stimulants induced by the debility and anxiety, the bodily and mental strain, which her condition in life rendered unavoidable.  

 

A hundred years ago

100 years ago: Prognosis in high blood pressure

25 May 2021Registered users

Ten and a half years ago I saw in consultation a lady of 62 years of age. Blood pressure, 195 mm.Hg. She had obvious shortness of breath, even when lying in bed. The heart was considerably enlarged, the rhythm tick-tack. She had persistent headaches and there was a mild grade of cyanosis. The vessels were degenerate, and she was sleepless and depressed. As onerous duties devolved on her, I was pressed by the relatives for a definite opinion on the outlook. I gave it as an opinion that, at the rate she was deteriorating, the chances were that she would not survive for more that a year. That was in 1909, and I still have the pleasure of seeing her now in 1921.

 

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 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.