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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

Early detection of liver cancer key to improving outcomes

07 Aug 2019Registered users

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 2019Registered users

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.

 

Special reports

Management of hypertensive disorders in pregnancy

07 Aug 2019Registered users

Hypertension is the most common medical complication of pregnancy, affecting 8-10% of pregnancies in the UK. It is associated with risks to both the woman and the fetus, with increased risks of pre-eclampsia, preterm delivery, fetal growth restriction, placental abruption and perinatal death. Any new onset of hypertension after 20 weeks or symptoms or signs suspicious of pre-eclampsia should be referred for same day assessment at a secondary care antenatal assessment unit.

Prompt detection vital in postpartum mood disorders

24 Jun 2019Paid-up subscribers

Common mental health disorders affect around one in five women during pregnancy and the first year following childbirth. Depression and anxiety disorders are the most prevalent mental health disorders during this period as they are at other times of life. It is important to distinguish postnatal depression from baby blues, which is common and requires no treatment, although it is a potential risk factor for postnatal depression. Postpartum psychosis affects 1 in 1,000 women and can develop very quickly in the first two weeks postpartum, often requiring urgent admission to a specialised mother and baby unit. One in six women with bipolar disorder will develop postpartum psychosis. 

Managing urinary incontinence in women

22 May 2019Paid-up subscribers

A detailed patient history is key to the assessment of patients with urinary incontinence and to guiding initial investigation and management. Clinical examination should include abdominal palpation to assess for masses, including an enlarged bladder. Visual inspection of the perineum and vagina helps determine whether the patient may be hypo-oestrogenic and can confirm the presence and grading of pelvic organ prolapse. Digital vaginal examination enables detection of masses, and an assessment of pelvic floor muscle strength. Urinalysis should also be carried out. Most patients will have either stress, urgency, or mixed urinary incontinence.

 

CPD exercises associated with each issue

CPD exercise - July/August 2019

07 Aug 2019Paid-up subscribers

All articles in The Practitioner online include fillable PDF frameworks for personal reflection on learning and drafting of plans for CPD. These templates are also included here in our standard study pack containing this month’s CPD exercise plus all relevant articles: • Optimising the treatment of inflammatory bowel disease • Early detection of liver cancer key to improving outcomes • Management of hypertensive disorders in pregnancy

 

Dermatology

Pruritus may be a symptom of underlying systemic disease

22 Mar 2018Paid-up subscribers

Itch is a common symptom of many dermatological conditions (e.g. eczema, urticaria and lichen planus) but can also be a manifestation of underlying systemic, neurological and psychological disorders, or an adverse reaction to medication. The assessment of patients with generalised itch but no rash requires a detailed history and examination to narrow the spectrum of potential causes. Examination should include inspection of the entire skin. Physical examination should include palpation for lymphadenopathy and organomegaly.

Diagnosing childhood eczema can be challenging

25 Sep 2017Registered users

Atopic eczema is the most common endogenous type of eczema in infants and children and affects around 15-20% of school-age children in the UK. Its prevalence is highest in children under the age of two and subsequently diminishes with age. It has a chronic, relapsing course. An emergency referral to a dermatologist or paediatrician should be made via telephone when there is a suspicion of eczema herpeticum or eczema coxsackium. Other indications for referral include diagnostic uncertainty, recurrent secondary infection, when control remains poor despite topical treatments, and for patients with emotional distress or significant sleep disturbance.

Managing actinic keratosis in primary care

24 Oct 2016Registered users

Actinic, or solar, keratosis is caused by chronic ultraviolet-induced damage to the epidermis. In the UK, 15-23% of individuals have actinic keratosis lesions. Dermatoscopy can be helpful in excluding signs of basal cell carcinoma when actinic keratosis is non-keratotic. It is always important to consider the possibility of squamous cell carcinoma. The principal indication for referral to secondary care is the possibility of cutaneous malignancy. However, widespread and severe actinic damage in immunosuppressed patients also warrants referral.

 

Sepsis

Diagnosing and managing sepsis in children

23 Jan 2018Registered users

The clinical features of sepsis are: fever; tachycardia, with no other explanation; tachypnoea, with no other explanation; leukocytosis or leucopenia. To meet the International Pediatric Sepsis Consensus Conference definition, a patient should have two of these features, one of which should be fever or abnormal white cell count, in the presence of infection. Every time a child who has symptoms or signs suggestive of infection is assessed, it is important to consider whether this could be sepsis. This may seem obvious in a child presenting with fever, but not all children with sepsis present with high fever or focal signs.

Have a high index of suspicion for sepsis in primary care

23 Oct 2017Registered users

The incidence of sepsis in the UK is estimated at 200,000 cases a year. Around 70% of cases of sepsis originate in the community. Most infections are self-limiting and can be managed outside hospital. However, patients with sepsis will deteriorate rapidly and each hour of delay to antibiotic administration is linked to decreased survival by 7.6%. Infants (< 1 year) and the elderly (> 75 years) seem to be far more likely to progress to sepsis than others. The assessment of sepsis in primary care should be standardised and include measurement of temperature, heart rate, respiratory rate, blood pressure, level of consciousness and oxygen saturation in young people and adults.

 

Post traumatic stress disorder

Identifying patients with complex PTSD

01 Aug 2016Registered users

Type 2 or complex trauma results from multiple or repeated traumatic events occurring over extended periods. Complex trauma is often associated with other adversity and stressors such as neglect, loss or deprivation. For many individuals these traumas occur at a developmentally vulnerable time with the perpetrator often in a caregiving role. Patients who have experienced complex trauma should be assessed for the core symptoms of PTSD. In addition, patients should be assessed for disturbances in the three domains of emotional dysregulation, negative self-concept and interpersonal disturbances.

Be vigilant for post-traumatic stress reactions

23 May 2016Registered users

The diagnosis of post-traumatic stress disorder (PTSD) differs from most psychiatric disorders as it includes an aetiological factor, the traumatic event, as a core criterion. The DSM 5 core symptoms of PTSD are grouped into four key symptom clusters: re-experiencing, avoidance, negative cognitions and mood, and arousal. Symptoms must be present for at least one month and cause functional impairment.

 

Neurology

Diagnosis and management of sleep-related epilepsy in adults

24 Sep 2018Registered users

Nocturnal epilepsies account for 10-15% of all epilepsies, and 80% of nocturnal epilepsies in adults are focal. They present a diagnostic challenge as they can be difficult to differentiate from normal movements and behaviour during sleep and also from several non-epileptic, sleep-related, motor and behavioural disorders. More than 90% of the seizures in sleep-related hypermotor epilepsy (SHE) occur during sleep. Seizures in SHE are simple partial seizures which easily wake the patient so that they will usually be able to recall the seizures, often describing auras of somatic sensations or feeling unable to breathe. SHE seizures have a rapid onset and offset, a short duration (usually < 2 min), and a stereotyped motor pattern for that individual.

 

Editorials

What is the optimal antidepressant dose?

07 Aug 2019Registered users

The optimal dose of a second-generation antidepressant lies towards the lower end of its licensed dose range, a systematic review and dose-response meta-analysis has found.

 

Research reviews - by GPs with a special interest

Lack of legacy effect from tight glycaemic control in type 2 diabetes

07 Aug 2019Paid-up subscribers

Adults with type 2 diabetes who had received intensive glucose lowering therapy for nearly six years had a lower risk of cardiovascular events than those who received standard therapy only during the prolonged period in which the HbA1C curves were separated, a study from the US has found. There was no evidence of a legacy effect or a mortality benefit with intensive glucose control 15 years after commencement of the study.

Gabapentinoids may increase risk of suicidal behaviour in young patients

07 Aug 2019Paid-up subscribers

A large Swedish study has suggested that gabapentinoid medications are associated with an increased risk of suicidal behaviour and unintentional overdose in adolescents and young adults.

How does weight change affect risk of atrial fibrillation?

07 Aug 2019Paid-up subscribers

Putting on weight appears to raise the risk of developing atrial fibrillation (AF), a meta-analysis  by investigators in Oxford, UK, has concluded. However, no clear evidence emerged as to whether weight loss reduces the risk.

High levels of cardiorespiratory fitness associated with reduced risk of COPD

07 Aug 2019Paid-up subscribers

Good cardiorespiratory fitness in midlife may lower the risk of developing and dying from COPD, a prospective cohort study from Denmark has found.

 

HASLAM's view

Medical terminology can provide food for thought

07 Aug 2019Registered users

I have always been fascinated by the way doctors tend to use foodstuffs to describe pathological conditions. The most extraordinary description I ever came across in a medical journal was an academic paper that described a tumour as being the size of a medium kumquat.

 

A hundred years ago

100 years ago: Excess of saccharide in modern diet

07 Aug 2019Registered users

Before man learnt to till the soil his supply of pure sugar was limited to wild honey. Now he extracts thousands of tons from artificially grown sugar-cane and beet. The consumption of sugar has within recent times increased enormously in our country, and many people eat much more than is good for them

 

A hundred and fifty years ago

150 years ago: Ergot of rye in the treatment of mania

07 Aug 2019Registered users

The beneficial effects of ergot in certain forms of mental disease are to be attributed to its controlling power over the intracranial vessels. In 200 cases of insanity in which I have employed ergot, I have found it useful in none in which the theory of its action which I have suggested was not available; while in all those in which it has proved most advantageous, this theory was vindicated in various ways.

 

Lead research reviews of 2019

Antiretroviral treatment in gay men minimises risk of HIV transmission

24 Jun 2019Registered users

There is effectively zero risk of HIV transmission in gay men through condomless sex when HIV viral load is adequately suppressed, the findings of the PARTNER2 study, published in the Lancet, suggest.

Do 5 alpha-reductase inhibitors raise the risk of type 2 diabetes?

22 May 2019Registered users

Finasteride and dutasteride appear to be associated with a modest increase in the risk of developing type 2 diabetes, according to the findings of a retrospective cohort study.

Regular cannabis use raises risk of psychosis

24 Apr 2019Registered users

Daily cannabis use is associated with a three-fold increased risk of psychotic disorder, a multicentre, international case-control study has shown.