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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

Managing bothersome LUTS

23 Apr 2020Registered users

Lower urinary tract symptoms (LUTS) in men can be defined by clinical symptoms arising from the bladder, bladder neck, urethral sphincter, urethra or prostate. Benign prostatic hyperplasia (BPH) is the most common cause of LUTS. By 80 years of age almost 90% of men have developed BPH at varying symptomatic levels. If the patient’s symptoms and examination findings are suspicious of cancer then an urgent two week wait referral should be made to urology. Other reasons for referral include: complicated LUTS with recurrent or persistent UTI, retention, renal impairment, stress incontinence or bothersome LUTS not resolved by conservative or drug management.

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.

 

Editorials

COPD patients at high risk of lung cancer regardless of smoking status

23 Apr 2020Registered users

Chronic obstructive pulmonary disease (COPD) is a strong, independent risk factor for the development of lung cancer in patients who have never smoked, a large population-based cohort study from South Korea has found. The risk of lung cancer in COPD patients who had never smoked was higher than in smokers who did not have COPD.

One in three doctors suffer burnout

24 Mar 2020

Nearly a third of doctors who responded to an online survey had high levels of burnout, and just over a quarter had high levels of secondary traumatic stress, a UK study has found. Only 6% of doctors had the optimal combination of low burnout, low secondary traumatic stress and high compassion satisfaction, whereas 8% had the worst combination of high burnout, high secondary traumatic stress and low compassion satisfaction.

 

Special reports

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.

Dermoscopy is a valuable diagnostic aid in primary care

24 Mar 2020

Dermoscopy as a clinical tool was developed primarily to evaluate pigmented lesions, particularly suspected melanoma. It is also useful in many other clinical situations, including the evaluation of a variety of benign and malignant skin tumours, inflammatory conditions, hair disorders, connective tissue diseases, and common infections and infestations. Images can be archived or exported for a second opinion and can also be shown to, and discussed with, the patient.

 

Research reviews - by GPs with a special interest

Exercise improves function and mortality rates in older patients following ACS

23 Apr 2020Paid-up subscribers

A largely home-based exercise intervention improved grip strength, mobility, daily activities and quality of life in older patients after acute coronary syndrome, an Italian study has shown. Hospitalisation and death rates were also reduced by the intervention. A total of 235 patients, median age 76 years, range 73-81 years, were recruited to the trial conducted at three sites in Italy. They were randomised one?month after their ACS event to the exercise or control group. All had reduced physical performance defined by the short physical performance battery with scores of 4-9.

Smoking in pregnancy increases fracture risk in infants

23 Apr 2020Paid-up subscribers

Intrauterine exposure to maternal smoking is associated with an increased risk of fractures in the first year of life, a national cohort study from Sweden has found. The study cohort comprised 1,680,307 live born singletons in Sweden, born between 1 January 1983 and 31 December 2000, followed up until 31 December 2014.

Substance use disorder raises risk of treatment resistant depression

23 Apr 2020Paid-up subscribers

Recent or current substance use disorder is associated with treatment resistance in patients who receive prescription treatment for depression, a nested case control study has found.

Exercise can improve functional status in diabetic neuropathy

24 Mar 2020Paid-up subscribers

Physiotherapy to improve ankle strength and balance produced sustained improvements in functional status in patients with diabetic peripheral neuropathy, in a study from Singapore.

 

Cancer

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.

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. 

Diagnosing and managing colorectal cancer

25 Jul 2018

Colorectal cancer is the fourth most common cancer in the UK and is the second most common cause of cancer deaths. Most cancers are thought to develop from colonic adenomas and incidence is strongly related to age. The majority of cancers are left sided and typically present with a change in bowel habit, blood in the stool or colicky abdominal pain. Rectal cancers can present with fresh red bleeding and large tumours can cause tenesmus (the intense and frequent desire to defecate, with little or no stool passed). Right-sided cancers most often present with anaemia. In both right- and left-sided cancers occasionally the patient may notice an abdominal mass or inexplicable 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.

Diagnosis and management of oesophageal cancer

22 Feb 2018

Oesophageal cancer commonly presents with dysphagia or odynophagia and can be associated with weight loss and vomiting. Referral for urgent endoscopy should always be considered in the presence of dysphagia regardless of previous history or medication. NICE recommends urgent referral (within 2 weeks) for direct access for upper GI endoscopy in patients with dysphagia and those aged 55 years or over with weight loss and any of the following: upper abdominal pain, reflux, or dyspepsia.

 

Cardiovascular disease

Diagnosis and management of hypertension in primary care

24 Feb 2020Registered users

NICE stipulates that two of the following are required for the diagnosis of hypertension: clinic blood pressure (BP) 140/90 mmHg or higher and ambulatory BP monitoring daytime average or home BP monitoring average 135/85 mmHg or higher. Evaluation of newly diagnosed hypertension includes an assessment of underlying cardiovascular disease (CVD) risk and target organ damage. Treatment threshold varies with underlying risk. For those at lower risk (< 10% risk of a CVD event over 10 years), drug treatment is not recommended below 160/100 mmHg.

Reducing stroke risk in patients with atrial fibrillation

25 Nov 2019Paid-up subscribers

Stroke is the most debilitating complication of atrial fibrillation (AF). AF-related strokes account for 20-25% of all strokes and are generally more severe and disabling and more likely to recur. Oral anticoagulation (OAC) remains the cornerstone of AF management with a clear prognostic benefit. It reduces stroke risk by two-thirds and mortality by a quarter. The decision to anticoagulate is taken irrespective of the pattern and duration of AF (paroxysmal, persistent or permanent). A large evidence base supports the use of OAC in men with a CHA2DS2-VASc score of 2 or more and women with a score of 3 or more. Hence, in the absence of absolute contraindications, OAC is strongly recommended.

 

Headache

Tackling medication overuse headache in primary care

24 Sep 2018Paid-up subscribers

Medication overuse headache (MOH) occurs as a complication of the management of primary headache disorders, mainly migraine and tension type headache. MOH does not occur in cluster headache unless there is associated migraine. MOH is defined as headache occurring on 15 or more days per month, that has evolved in association with the frequent use of acute medication over a period of more than 3 months. Any medication used for the acute treatment of headache can cause MOH.

Diagnosis and management of migraine in primary care

22 May 2018Paid-up subscribers

The Landmark study, from 15 countries, reported that 94% of patients attending a GP with episodic disabling headache had migraine. Generally, an untreated migraine headache is moderate to severe and lasts for more than four hours. It is often pulsating, but patients may describe a feeling of ‘expanding pressure’ within the head. Most sufferers experience nausea although fewer patients actually vomit. Acute treatment should be taken as soon as a migraine headache starts to develop as later in the attack central sensitisation occurs and treatments become less effective.

 

HASLAM's view

The therapeutic power of music put to the test

24 Apr 2020

A study which was due to be presented at the American College of Cardiology’s annual scientific session showed that the addition of regular music therapy to standard pharmacological therapy can lead to lower levels of anxiety and pain after heart attacks, as well as a significant reduction in heart failure. Music may not protect us from coronavirus, but it certainly still has plenty to offer to all of us – whether as patients, clinicians, or citizens. Play on….

Combatting fear and uncertainty

24 Mar 2020

Few such serious global health issues as coronavirus have appeared in my entire professional lifetime. The astonishing speed of developments means that what I write today may be outdated tomorrow, let alone in a few weeks when you will be reading this. However, if I ignore the topic, it’s all too clear that I’m not living in the real world of contemporary healthcare. I can only hope that by the time you do read this, I’ll be living in the real world – full stop. For clinicians, their families, indeed for great swathes of the population, these are incredibly difficult times, combining uncertainty with fear.

Life is for living in old age

24 Feb 2020

When families put pressure on GPs to get a relative ‘put into a home,’ we can often see the logic of the request. Yet we know that going into a home may take away the final vestiges of individuality from an old person who still loves their cat, their flat and their possessions – however chaotic and untidy their life may seem.

 

A hundred years ago

100 years ago: Medico-legal notes: Malingering ii

23 Apr 2020Registered users

The case gave rise to some suspicion, it was referred to a medical man, who fearlessly  reported that the case was one of malingering; but his opinion was not acted upon, and A.E. for many months was paid compensation for right-sided “drop-wrist”. He appears to have been no mean actor, for whilst he simulated paralysis of the right wrist so well as to obtain weekly certificates of incapacity, he was actually engaged in giving performances as a professional strong man. Every night at a music hall, clad only in gorgeous harness, he lifted enormous weights. One of his demonstrations consisted in stiffening the muscles of the right forearm and wrist, and breaking with his right hand a thick strap which passed diagonally over from his right shoulder to his left hip!

100 years ago: Psychotherapy in civil practice

24 Mar 2020Registered users

A CHILD OF EIGHT once said to me: “I like going to sleep, because I dream, and when I dream I can be as naughty as I like without being punished.” That, indeed, contains the whole essence of the dream science.  In our dreams we are as naughty as our primitive self desires to be; we get what we want and  hang the consequences, but the moral censor within us insists on camouflage, and the dream as it presents itself to our consciousness is but an anaemic representative  of the full-blooded wish which inspired it.

 

A hundred and fifty years ago

150 years ago: A case of enteric fever with convulsions

23 Apr 2020Registered users

PETER O'C AGED 18, a compositor in the office of the Evening Post, was admitted into Sir P. Dun’s Hospital on the morning of the 14th December in 1870 with all the symptoms of well-marked enteric fever. He had the rose-coloured spots, caecal gurgling, with tympany and diarrhoea; when comparatively late in the fever, convulsions and other cerebrospinal symptoms manifested themselves. As far as we could learn he was about eleven days in fever.  He was rather inclined to sleep, and for several days seemed to be getting on favourably, and the diarrhoea ceased, receiving eight ounces of wine.  On Saturday night, about half-past ten o’clock, the patient was noticed to be lying on his back, low down in the bed, with his arms folded over his chest; his breathing was rapid and irregular, a circumstance noted during the afternoon, without any chest complication to account for it. When spoken to he made no reply, nor did he stir, but when turned on his side he spoke a few words and swallowed some whiskey in milk. A blister was applied to the nape of the neck.

150 years ago: Vagal compression as an alternative to chloroform

24 Mar 2020Registered users

IN CASES OF DISLOCATED BONES of difficult reduction vagal pressure presents several advantages possessed by no other means with which I am acquainted, as it is unattended with any kind of danger, and is always at hand in any emergency, however sudden. 

150 years ago: Morphia by subcutaneous injection in an elderly person with sciatica

24 Feb 2020Registered users

THE SUBCUTANEOUS INJECTION of morphia has become a comparatively common household remedy among certain classes of society for some years past. More especially among the very numerous persons, chiefly women, who suffer either from neuralgia, or even from attacks of nervous depression and sleeplessness without positive pain, it has become a too common practice to inject themselves, or to get injected by their servants, whenever they feel symptoms.

150 years ago: Reduction of pitting from small-pox

23 Jan 2020Registered users

THE TERRIBLE SEAMING and pitting of the face, neck and other exposed parts of the body so often consequent on bad attacks of small-pox are universally known. Reference, however, is seldom made to the total exemption of the scalp from marking of any kind, after even the severest form of this disease. It recently occurred to me, from watching a photographer using cotton-wool to shut out light in the process of ‘vignetting’ photographs, that this material, if applied to the face and neck of small-pox patients, might give a protecting influence somewhat similar to that afforded to the scalp by the hair, and thereby prevent or modify the subsequent pitting.