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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. It is also used by doctors preparing for work in the UK. All articles in The Practitioner online include CPD fillable PDF 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.

 

Special reports

History taking the key to diagnosing food allergy in children

25 Jul 2018Paid-up subscribers

Allergy to milk and egg are the two most prevalent food allergies in children. They are typically diagnosed in infancy and carry a good prognosis with the majority of cases resolving before the child reaches school age. Other allergies may present later in childhood and are more likely to persist. There is evidence of a causal link between early onset severe and widespread eczema that is unresponsive to moderate topical steroids and development of IgE mediated food allergy, in particular peanut allergy. The EAT study showed that infants who were weaned early and exposed to egg and peanut had a significant reduction in allergy to both foods.



Tailor BP targets to the older patient with hypertension

25 Jun 2018Paid-up subscribers

The prevalence of hypertension increases with age and older people are likely to benefit more from BP reduction because of their high baseline cardiovascular risk. However, older people are a very heterogeneous group and a single BP target will not be appropriate for all. Current evidence is based on ambulatory or healthy older populations as patients with significant complex conditions were not represented in randomised clinical trials. 

Diagnosis and management of migraine in primary care

22 May 2018Registered users

Migraine is common, with a global prevalence of 14.7% and a lifetime prevalence in the UK of 20-25%. A UK study found that there were 4.44 consultations for headache per 100 registered patients aged = 15 years per annum. The Landmark study, from 15 countries, reported that 94% of patients attending a GP with episodic disabling headache had migraine.

 

Men's health - Temporary access

Identifying and managing men with early prostate cancer

23 Apr 2018

Prostate cancer is the most common cancer in men in the UK. Men have a 1 in 8 lifetime risk of being diagnosed with the disease. Factors associated with an increased risk of prostate cancer include: age > 50 years, black ethnicity, a first-degree relative with prostate cancer, and obesity. Patients may present with erectile dysfunction or lower urinary tract symptoms such as frequency, hesitancy, nocturia, or haematuria.

Managing acute and chronic urinary retention in men

23 Apr 2018

Urinary retention is the most common urological emergency and more than 95% of cases occur in men. Acute urinary retention (AUR) is defined as the sudden inability to pass any urine voluntarily associated with a painful, palpable or percussable bladder. In chronic urinary retention (CUR) there is a non‐painful bladder, which remains palpable or percussable after the man has passed urine, with a post-void residual volume > 300 ml. In acute on chronic urinary retention no urine can be voluntarily passed but the condition is relatively painless and the residual volume on catheterisation is > 1.5 litres.

Diagnosing and managing androgen deficiency in men

24 Apr 2017

Androgens play a crucial role in bone, muscle and fat metabolism, erythropoiesis and cognitive health. In men aged 40-79 years the incidence of biochemical deficiency and symptomatic hypogonadism is 2.1-5.7%. Decreased libido or reduced frequency and quality of erections, fatigue, irritability, infertility or a diminished feeling of wellbeing may be presenting complaints. However, a significant proportion of men with androgen deficiency will be identified when they present for unrelated concerns.

Diagnosing testicular lumps in primary care

24 Apr 2017

Although the incidence of testicular cancer has increased over the past few decades, testicular tumours are still rare and many GPs will only see one or two new diagnoses in their career. When examining scrotal swellings, the key question is whether the lump is intra- or extra-testicular, as palpable intra-testicular lesions are highly likely (around 90%) to be malignant, whereas those lying outside the testis are usually benign.

Managing lower urinary tract symptoms in men

25 Apr 2016

Up to 90% of men aged 50 to 80 may suffer from troublesome lower urinary tract symptoms (LUTS). A thorough urological history is essential to inform management. It is important to determine whether men have storage or voiding LUTS or both. Based on history, examination and investigation findings an individualised management plan should be formulated.

Careful assessment key in managing prostatitis

23 Apr 2015

Prostatitis is a common condition estimated to affect up to 30% of men in their lifetime, it is most prevalent in men aged between 35 and 50. Prostatitis is subclassified into: acute bacterial prostatitis, chronic bacterial prostatitis, chronic pelvic pain and asymptomatic inflammatory prostatitis. Clinical assessment includes a thorough history and examination. A digital rectal examination should be performed after a midstream urine sample has been collected for urine dipstick, microscopy and culture. The prostate should be checked for nodules.

 

Women's health

Early treatment vital in pelvic inflammatory disease

23 Apr 2018Paid-up subscribers

Pelvic inflammatory disease (PID) is caused by infection ascending from the cervix. It can affect the uterus, fallopian tubes, ovaries, and peritoneum. Important sequelae include infertility, ectopic pregnancy and tubo-ovarian abscess. PID is associated with sexually transmitted infections. These are more prevalent in younger women. A diagnosis of PID should be considered in any sexually active woman with recent onset pelvic pain associated with tenderness on bimanual examination where other differentials have been excluded. Delay in commencing treatment for PID has been shown to increase the risk of long-term complications.

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.

 

A hundred and fifty years ago

150 years ago: Delirium tremens treated by the spinal icebag

25 Jul 2018Registered users

When admitted he was perspiring freely; his face and eyes were congested; his tongue moist, and coated with creamy fur; his pulse was slow, full, but very compressible, and his hands were tremulous.  For the last twenty years he had led an intemperate life, ‘and having become a tavern-keeper,’ he drank night and day for about six months, and had not ceased up to the time of his admission. He was treated successively by means of capsicum, tartar-emetic with opium every second hour, a stream of water directed from a height of some feet on his head, and an enema containing tincture of opium and tincture of bella donna. All the remedies tried have proved of no avail. ...

 

Symposium

Improving outcomes in pancreatic cancer

25 Jul 2018Registered users

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.

Diagnosing and managing colorectal cancer

25 Jul 2018Registered users

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.

 

Clinical reviews of research - by GPs with interest

Improvement in glycaemic control in type 1 diabetes tails off after five years

25 Jul 2018Registered users

In patients with type 1 diabetes, clinically meaningful and sustained HbA1c improvement rarely occurs more than five years after diagnosis, a UK study has found.

Can nicotine preloading help smokers quit?

25 Jul 2018Registered users

The use of a nicotine patch before quitting may have a modest effect on abstinence, a large pragmatic randomised trial has found. A total of 1,792 adults were enrolled from Nottingham, Birmingham, Bristol, and London.

 

Editorials

Anticholinergic drugs and risk of dementia

25 Jul 2018Paid-up subscribers

Antidepressant, urological and anti-parkinsonian drugs with definite anticholinergic effects are associated with an increased risk of incident dementia up to 20 years after exposure, a UK nested case-control study has found. The study authors conclude: 'Clinicians should continue to be vigilant with respect to the use of anticholinergic drugs, and should consider the risk of long-term cognitive effects, as well as short-term effects, associated with specific drug classes when performing their risk-benefit analysis.'

GP auscultation a poor predictor of valvular heart disease

25 Jun 2018Paid-up subscribers

Auscultation has only limited accuracy in the detection of valve disease in asymptomatic patients and is a poor diagnostic screening tool in primary care, a UK study has found.

How effective are antidepressants?

22 May 2018Paid-up subscribers

All antidepressants are more efficacious than placebo in adults with major depressive disorder, a systematic review and meta-analysis has found. Double-blind, randomised controlled trials were identified from the Cochrane Central Register of Controlled Trials and other large databases. Placebo-controlled and head-to-head trials of 21 antidepressants (a selection of first-generation and all approved second-generation antidepressants) were included.

 

HASLAM's view

Living near your practice can be a double-edged sword

25 Jul 2018Registered users

Living in the middle of the patch had a number of unexpected consequences. The most bizarre experiences tended to occur during social events. I will never forget the time I was taking part in a local charity fundraising fancy dress event dressed as Superman. Someone came up to me to ask if I would visit her granny the next week. Trust me, there is nowhere to store a notebook in a Superman outfit to record a request for a home visit.

 

CPD exercises associated with each issue

CPD exercise July/Aug 2018

25 Jul 2018Paid-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: • Improving outcomes in pancreatic cancer • Diagnosing and managing colorectal cancer • History taking the key to diagnosing food allergy in children