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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

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.

Have a high index of suspicion for ectopic pregnancy

24 Mar 2020Registered users

Ectopic pregnancy is estimated to occur in 1-2% of all pregnancies and continues to be the leading cause of maternal mortality in early pregnancy. Most ectopic pregnancies are located within the fallopian tube and carry a risk of tubal rupture and intra-abdominal bleeding. Women with ectopic pregnancy can present in a wide variety of ways, from acute collapse following rupture to asymptomatic and unaware that they are pregnant. Symptoms may include vaginal bleeding and abdominal pain. There may also be non-specific symptoms such as Gl and urinary symptoms, rectal pressure, dizziness, shoulder tip pain, fainting or syncope. 

 

Special reports

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.

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.

 

Research reviews - by GPs with a special interest

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.

Weight gain associated with accelerated lung function decline

24 Mar 2020Paid-up subscribers

Adults who put on weight over a 20-year period had a more rapid decline in FVC and FEV1, a large international population-based study has shown. However, weight loss was found to attenuate the decline.

LARC uptake increases in young women

24 Mar 2020Paid-up subscribers

There has been a significant increase in the use of long-acting reversible contraception in women under 25 over the past decade, a national survey has found. However, condoms and the oral contraceptive pill are still the most commonly used methods.

Are psychological techniques effective in patients at high risk of CVD?

24 Mar 2020Paid-up subscribers

Enhanced motivational interviewing with additional behaviour change techniques was not effective in reducing weight or increasing physical activity in patients at high risk of cardiovascular disease, a primary care study has shown.

 

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.

 

Gastroenterology

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 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.

 

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.

Rapid diagnosis vital in thunderclap headache

25 Apr 2016Registered users

Thunderclap headache is a severe and acute headache that reaches maximum intensity in under one minute and lasts for more than five minutes. Thunderclap headaches may be associated with symptoms such as photophobia, nausea, vomiting, neck pain, focal neurological symptoms or loss of consciousness. Subarachnoid haemorrhage (SAH) accounts for 10-25% of all thunderclap headaches and, despite advances in medical technology, has a 90-day mortality of 30%. Up to a quarter of cases of SAH are misdiagnosed, often through failure to follow guidance.

 

Managing patients with cluster headache in primary care

23 Sep 2013Registered users

Cluster headache is a strictly unilateral headache that occurs in association with cranial autonomic features. The diagnosis is purely clinical and it is therefore crucial to take a good history looking for its distinctive features. Specialist advice should be sought: at first presentation for confirmation of diagnosis, and development of a plan for managing current and future cluster bouts; and where first-line treatments fail.

 

HASLAM's view

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.

 

Editorials

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.

Infant vaccination schedule leads to significant fall in meningitis B

24 Feb 2020Registered users

The infant vaccination programme against meningitis B introduced in the UK in 2015 has been highly effective, a study from Public Health England has confirmed. The research team evaluated the effect of infant vaccination on the incidence of meningococcal group B disease during the first three years of the programme from September 2015 to August 2018. There was a 75% reduction in cases of meningitis B in age groups that were fully eligible for vaccination.

 

A hundred and fifty years ago

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.

 

A hundred years ago

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.

100 years ago: Medico-legal notes: Malingering

24 Feb 2020Paid-up subscribers

MANY WORKING MEN adopt a line of conduct which seems to necessitate their being branded as malingerers; but so to characterize them should never be done only when prepared with incontestable evidence of fraud.  However confident you are that the plaintiff is grossly exaggerating, is untruthful, and is attempting to deceive the Court, it is unwise to allege malingering unless it can be proved up to the hilt. Nothing pleases the plaintiff’s counsel better than for a medical witness to use the word malingerer, for he knows that he can then appeal to the class prejudice of the jury.