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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 treatment can arrest or reverse cirrhosis

24 Jul 2020Registered users

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 2020Registered users

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.

 

Special reports

Optimising the management of depression in children

24 Jul 2020Registered users

In a large meta-analysis, the prevalence of depression was twice as common in adolescents (5.7%) than children (2.8%). The 2:1 female to male ratio of depression seen in adults becomes apparent from the age of 12 years. Three quarters of children aged 3-17 years with depression also have anxiety, and almost half have associated behaviour problems. Depression should be treated by child and adolescent mental health services unless the episode is mild and of < 2-3 months’ duration.

Diagnosis and management of thyroid dysfunction in primary care

22 Jun 2020Registered users

Hyperthyroidism affects up to 2% of women in the UK and the US and is ten times more common in women than men. In regions with normal levels of iodine, hyperthyroidism is caused by Graves’ disease in 60-80% of cases. In regions with iodine insufficiency toxic nodular disease (caused by toxic adenomas) accounts for 50% of cases of hyperthyroidism and this aetiology is more common in older people. Patients with hyperthyroidism should be referred. Overt hypothyroidism is present in 0.2-5% of the population and is more common in women and with advancing age. It is usually managed in primary care and rarely requires referral.

 

Research reviews - by GPs with a special interest

Lifestyle intervention reduces risk factors in older patients with coronary artery disease

24 Jul 2020Registered users

Patients aged 65 years and over with coronary artery disease benefitted at least as much as younger patients in improving lifestyle risk factors in a community-based trial from the Netherlands. Older patients were more likely to achieve the weight loss target and stop smoking. Younger patients were more likely to show no improvement in lifestyle risk factors.

Asthma persisting from childhood to adulthood presents a distinct phenotype

24 Jul 2020Registered users

Asthma that starts in childhood and persists throughout adult life tends to be more severe and is associated with poorer lung function compared with adult-onset asthma, a study from Japan has concluded. The difference in clinical characteristics points to a distinct phenotype.

Evaluating therapies for depression in children and adolescents

24 Jul 2020Registered users

Fluoxetine, either alone or in combination with CBT, appears to be the most effective treatment for children and adolescents with moderate to severe depression, a systematic review and network meta-analysis has concluded.

Patient safety incidents in opioid substitution therapy analysed

24 Jul 2020Registered users

Errors in prescribing, supervised or non-supervised dispensing, and monitoring and communication, were responsible for patient safety incidents in opioid substitution treatment, a study from England and Wales has shown.

 

Paediatrics

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.

Managing common skin conditions in infants

24 Jun 2019Paid-up subscribers

Atopic eczema, or atopic dermatitis, affects up to 20% of children and often presents in infancy. Cow’s milk allergy can also manifest as eczema and gastrointestinal (GI) symptoms. Food allergy should be suspected if there is a clear history of a reaction to a food in infants with moderate to severe eczema not responding to standard treatment, in infants with very early onset eczema (under 3 months) and those with GI symptoms. Seborrhoeic dermatitis is often an early manifestation of atopic eczema. Naevus simplex is a common congenital capillary malformation occurring in up to 40% of newborns. Port wine stains are less common, affecting about 0.3% of infants. 

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.

 

Women's health

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. 

Prompt detection vital in postpartum mood disorders

24 Jun 2019Registered users

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. 

 

Men's health

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.

 

Cancer - Open access

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.

 

Editorials

Physical activity significantly reduces all-cause and cause-specific mortality

24 Jul 2020Registered users

Following recommendations for both aerobic and muscle strengthening activity can reduce all-cause mortality by up to 40%, a study of nearly half a million adults in the United States has shown. Individuals who met the target for aerobic activity only also had a significant reduction in all-cause mortality risk of 29% and those who participated in just muscle strengthening exercise at recommended levels had a reduction in risk of 11%.

Inactivity and depression in adolescence

22 Jun 2020Registered users

Sedentary behaviour during adolescence is associated with an increased risk of depressive symptoms at the age of 18, a UK study has found. Healthcare practitioners should ensure that parents and carers are aware of government advice on how much physical activity children and young people should be doing (i.e. at least 60 minutes of moderate-vigorous activity per day). Adolescents should be routinely asked about physical activity and sedentary behaviour levels, and every opportunity taken to emphasise the mental health benefits of physical activity.

 

HASLAM's view

What made you choose your practice?

24 Jul 2020Registered users

Kindness and thoughtfulness matter hugely in any working relationship, probably far more than premises, academic brilliance, list size, workload or income. General practice is a team game, and whatever your role in the organisation it matters that we treat each other with civility and kindness. 

Is there a cure for loneliness?

22 Jun 2020Registered users

Loneliness really does matter, as so many people in this era of lockdown in the Covid-19 pandemic will personally confirm. Lonely people are more likely to visit their GP, have higher use of medication, higher incidence of falls and increased risk factors for long-term care. Loneliness is a serious problem. However, if anything demonstrates the potential overmedicalisation of society it must be the concept of prescribing medication to ease loneliness.

 

A hundred years ago

100 years ago: Where there's life there's hope

24 Jul 2020Registered users

HOPE IS THE?GREATEST?motive power in the world. As a strong moral force alike in matters temporal and spiritual, it would be strange if such a powerful incentive to action did not find its place in the practice of medicine.  It is a good rule never to “give up” on a patient; exceptions will occur no doubt in this as with most rules. To give up hope is to give up effort, and it is here the tragedy comes in. Cases illustrating the value of a “never give up hope” attitude crowd on the memory. Of course the most sanguine and persevering must expect failure at times, but he will have the satisfaction of having had a good try.

100 years ago: Use and abuse of psychoanalysis

22 Jun 2020Registered users

Doctors have done little to discourage the entry of the unskilled into becoming practitioners of psychoanalysis, a field which belongs to the trained physician. Unqualified practitioners abound both here and in America. Some medical men have encouraged lay efforts and are apt to express contempt for those who believe that mental ills may supervene on physical infirmities, or may be but evidence of a disorganized function.

 

A hundred and fifty years ago

150 years ago: Sarsaparilla therapy in syphilis

24 Jul 2020Registered users

The antisyphilitic effects of sarsaparilla depend upon the dose in which it is given. The treatment has been in use for a quarter of a century at least in the Leeds Infirmary and no one has yet published the results. The cases in which sarsaparilla is most useful are cases in which the system is thoroughly infected with syphilis, during the tertiary and visceral modes of its appearances.Two cases will do to illustrate my opinions.

150 years ago: Insanity and general debility

22 Jun 2020Registered users

IN 83 OF THE LAST 100 cases in my case book for the asylum, whose disease was under six months’ duration, there were symptoms of bodily disorder that could be directly connected with the psychical symptoms. One bodily disorder accompanying insanity I call ‘general debility’(13 of the 100 cases). There is great emaciation, no vigour or ability for bodily exertion, languor, and a sense of prostration. The mental symptoms in these cases are generally those of melancholy and depression of mind. There is often a sluggishness in the performance of even the organic bodily functions – a slow pulse, costive bowels, a weak circulation in the extremities, with cold feet, blue hands, and pinched features. This is without organic disease of any kind.