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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

Juvenile spondyloarthropathies often go unrecognised

25 Jun 2021Registered users

Juvenile spondyloarthropathy (JSpA) is an umbrella term encompassing enthesitis-related arthritis, juvenile onset ankylosing spondylitis, juvenile psoriatic arthritis, IBD-related arthritis and reactive arthritis. Initial assessment of any childhood arthropathy should include a full blood count with differentials and inflammatory markers (CRP and ESR), which will be normal in most cases of JSpA, or may reflect a mild inflammatory response and anaemia relating to chronic disease. RF and ANA are characteristically negative. Children with JSpA should be tested for HLA-B27. Children with suspected JSpA should be referred via their GP to a tertiary paediatric rheumatology centre.

Diagnosis and management of acute asthma in children

25 Jun 2021Registered users

Asthma affects 1.1 million children in the UK, and up to 50% experience asthma exacerbations each year. A previous asthma attack is the most important risk factor for future episodes. Modifiable risk factors include poor symptom control, suboptimal treatment regimens, over-reliance on SABAs and poor adherence to preventer therapy. Following an attack all children should receive asthma education as well as an updated personalised asthma action plan. Patients and/or parents must be able to demonstrate correct use of inhalers. A GP review should be carried out within two working days of an asthma attack.

 

Special reports

Improving the detection of cutaneous squamous cell carcinoma

25 Jun 2021

Cutaneous squamous cell carcinoma (cSCC) can develop de novo or from pre-existing chronic actinic damage, although the probability and speed of transition from actinic keratosis to cSCC is highly variable. The occurrence of cSCC is related to chronic UV exposure, particularly occupational exposure. Risk factors include fairer skin, significant exposure to sunlight or PUVA. Incidence is also significantly increased in patients who are immunosuppressed. All patients with suspected cSCC should be referred via the two-week wait pathway to dermatology.

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.

 

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.

 

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.

 

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. 

 

Cancer - Temporary direct access

Improving the detection of cutaneous squamous cell carcinoma

25 Jun 2021

Cutaneous squamous cell carcinoma (cSCC) can develop de novo or from pre-existing chronic actinic damage, although the probability and speed of transition from actinic keratosis to cSCC is highly variable. The occurrence of cSCC is related to chronic UV exposure, particularly occupational exposure. Risk factors include fairer skin, significant exposure to sunlight or PUVA. Incidence is also significantly increased in patients who are immunosuppressed. All patients with suspected cSCC should be referred via the two-week wait pathway to dermatology.

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. 

 

Editorials

Weighing up the risks and benefits of tight blood pressure control

25 Jun 2021Registered users

Intensive blood pressure (BP) control results in significantly better cardiovascular outcomes and lower all-cause mortality in those at increased risk compared with routine BP control, the Systolic Blood Pressure Intervention Trial (SPRINT) has found. However, serious adverse events such as hypotension, electrolyte abnormalities, acute kidney injury or failure, and syncope were also significantly more frequent in the intensive treatment group.

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.

 

HASLAM's view

Working life friendships make our working lives special

25 Jun 2021Registered users

Whatever the brave new world that faces us in the future, we all have to remember that while efficiency, cost-effectiveness and outcomes all really matter, it is the friendships that make our working lives something special.

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.

 

Research reviews - by GPs with a special interest

Non-consensus TIA raises early and long-term risk of stroke

25 Jun 2021Registered users

Patients with non-consensus transient ischaemic attack (TIA) have a raised seven-day risk of stroke, the Oxford Vascular Study (OXVASC) has found. The ten-year risk of all major vascular events was similar for non-consensus and classic TIAs.

Even smoking some days increases risk of premature death

25 Jun 2021Registered users

Individuals who do not smoke every day have a significantly higher risk of all-cause mortality compared with those who have never smoked. For those who smoke daily, the mortality risk increases as the number of cigarettes smoked increases, a large study from the USA has found.

Breaking bad news to parents about their child’s prognosis

25 Jun 2021Registered users

Parents of children facing terminal or life-threatening illnesses require timely information about their child’s prognosis from healthcare professionals and an opportunity to provide input into the discussion, a qualitative study from the Netherlands has found.

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.

 

A hundred and fifty years ago

150 hundred years ago: Case study of a man who can walk 1,200 miles in 30 days

25 Jun 2021Registered users

Mr Weston is an extraordinary man. He has accomplished the most wonderful feats of endurance, always without having gone through a regular system of training. He walked, a few days ago from Portland to Chicago, a distance of about 1,200 miles in thirty consecutive days, resting four Sundays, and this in the early winter, through mud, rain, and snow; and he is apparently as well after such efforts as before. Mr Weston has an ill-judged contempt for training. He takes no regular exercise, and does not restrict his diet before his greatest efforts. About a week after a hundred mile walk, he walked fifty miles in less than 10 hours. The night before the attempt, at 2 A.M., he was eating pork and beans preparatory to going to bed.

 

A hundred years ago

100 years ago: Lessons to be learned from the mistakes of others II

25 Jun 2021Registered users

MISTAKES MAY BE CLASSIFIED under two headings: trivial errors made by ourselves, and glaring blunders made by other people. This second article in my series continues to highlight the mistakes of other people.

 

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.

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.