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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 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

Managing mild to moderate asthma in adults

22 Nov 2018

The National Review of Asthma Deaths found that most patients who died were actually considered to have mild to moderate asthma, with 57% of fatal cases not under specialist care at the time of their death. In cases of fatal asthma there was widespread underuse of inhaled corticosteroids and an overreliance on short-acting beta-agonists. Referral to secondary care should take place when there is diagnostic uncertainty or atypical features, the possibility of hypersensitivity to inhaled material or concerns over treatment or exacerbations. Patients who have suffered even a single life-threatening asthma attack should be under specialist supervision. 

Diagnosing and managing cystic fibrosis in children

22 Nov 2018Registered users

Cystic fibrosis (CF) is a multisystem genetic disorder affecting around 1 in 2,500 live births in the UK. Although all newborns undergo screening for CF, around 15% of infants will present shortly after birth with meconium ileus and some will already have faltering growth when the screening results are available at 3-4 weeks of age. Infants who present with meconium ileus should be treated with a high index of suspicion for CF until proven otherwise. Mucociliary dysfunction leads to accumulation of mucus in the airways and secondary infection. Respiratory symptoms may be non-specific initially and include cough and wheeziness, frequent respiratory infections and, in older children, sinusitis.

Managing complications of cystic fibrosis in adults

22 Nov 2018Registered users

Overall survival has improved dramatically for patients with cystic fibrosis (CF) since the millennium such that median life expectancy now extends into the fifth decade. However, with increasing longevity comes a range of comorbidities, some as complications of the disease itself but others as a consequence of long-term treatments required to manage CF. Chronic infection and inflammation eventually cause irreversible bronchiectasis and decline in pulmonary function, and 90% of CF deaths are caused by progressive respiratory failure.

 

Special reports

Early recognition and prompt referral key in acute pancreatitis

22 Oct 2018Registered users

Early recognition, prompt referral to secondary care and close monitoring for complications is important in improving outcomes in acute pancreatitis. The diagnosis of acute pancreatitis should be considered in any patient presenting with abdominal pain. The most common pattern of pain is severe epigastric pain that radiates to the back, is exacerbated by movement, and is alleviated by sitting forwards.

 

Dermatology - Temporary access

Improving detection of non-melanoma skin cancer

05 Aug 2015

Basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) are clinically and pathologically distinct and both are locally invasive. However, while BCCs rarely metastasise, SCCs have the potential to do so especially when they arise on the ears or lips. Patients with one non-melanoma skin cancer (NMSC) have a higher risk of developing another NMSC and of malignant melanoma.

GPs have key role in early detection of melanoma

24 Jun 2013

Lesions which have a high index of suspicion for melanoma should not be removed in primary care. Patients should be referred urgently to secondary care with a history recording the duration of the lesion, change in size, colour, shape and symptoms. 

 

Paediatrics

Managing acute asthma in children

25 Jun 2018

The BTS/SIGN guideline specifies that the accurate measurement of oxygen saturation is essential in the assessment of all children with acute wheezing. It recommends that oxygen saturation probes and monitors should be available for use by all healthcare professionals assessing acute asthma in primary care. It is important to use the appropriate size paediatric probe to ensure accuracy. Any patient who presents to the GP practice with any features of a moderate exacerbation should be referred to an emergency department for further assessment and monitoring. 

Diagnosing heart disease in children and adolescents

22 Jun 2017Paid-up subscribers

Heart disease in children and adolescents can be congenital, in which structural defects of the heart and major blood vessels are present from birth, acquired, whereby disease develops during life, or genetic, including diseases affecting the heart muscle, electrical system or the aorta. The incidence of congenital heart disease has decreased over the past 30 years, with approximately 1 in 180 babies born with congenital heart disease in the UK each year. Several cardiac diseases are genetic and can manifest in childhood. Most are primary cardiomyopathies, ion channel diseases, coronary artery disease from familial hypercholesterolaemia or aortopathies.

Optimising the management of wheeze in preschool children

23 Jun 2016Paid-up subscribers

One third of all preschool children will have an episode of wheeze and many of these present to primary care. Most will fall within a spectrum of diagnosis ranging from episodic viral wheeze to multiple trigger wheeze or early onset asthma. The child should be referred to hospital immediately if you suspect an inhaled foreign body or anaphylaxis (after administering IM adrenaline). NICE recommends immediate referral for children with wheeze and high-risk features and also those with intermediate-risk features failing to respond to bronchodilator therapy.

Optimising the management of bronchiolitis in infants

05 Aug 2015Registered users

Bronchiolitis shows a seasonal pattern with peak incidence occurring in the winter. Around 2-3% of children require admission to hospital. Admission rates are highest in infants less than three months old and those with underlying comorbidities. Infants will have a coryzal prodrome lasting one to three days before developing a persistent cough.

 

Gastroenterology

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.

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.

Be vigilant for non-alcoholic fatty liver disease in primary care

28 Jul 2017Registered users

Non-alcoholic fatty liver disease (NAFLD) is now the most common cause of chronic liver disease in the Western world. Between 10 and 30% of NAFLD patients will develop non-alcoholic steatohepatitis (NASH) with a risk of progression to cirrhosis. Of those with NASH and fibrosis at presentation, studies have suggested that approximately 21% of patients will have some regression of fibrosis while 38% of patients will progress over five years’ follow-up.

Chronic pancreatitis may be overlooked and undertreated

28 Jul 2017Registered users

The prevalence of chronic pancreatitis is variable, with estimates between 4 and 52.4 per 100,000. A mismatch exists between reported incidence and prevalence in many studies suggesting chronic pancreatitis is under recognised. One cause for this mismatch is that once diagnosed many patients are lost to secondary care follow-up. Therefore, although a GP may only see two new cases during their career they are likely to encounter patients requiring recurrent consultations.

 

Women's health

Managing debilitating menopausal symptoms

21 Mar 2016Paid-up subscribers

Severity and duration of menopausal symptoms varies markedly. Eight out of ten women experience symptoms and on average these last four years, with one in ten women experiencing symptoms for up to 12 years. Menopausal symptoms can begin years before menstruation ceases. A recent study found that women whose vasomotor symptoms started before the menopause suffered longest, median 11.8 years. Women whose hot flushes and night sweats started after the menopause had symptoms for a median of 3.4 years.

Be vigilant for perinatal mental health problems

23 Mar 2015Paid-up subscribers

The postnatal period appears to be associated with higher rates of adjustment disorder, generalised anxiety disorder, and depression. Women who have a history of serious mental illness are at higher risk of developing a postpartum relapse, even if they have been well during pregnancy. Postnatal depression is more severe than baby blues, follows a chronic course and may relapse outside the perinatal period. Bipolar disorder may present as a first depressive episode in pregnancy or the postnatal period. In the postpartum period women have a high risk of severe relapse.

 

Editorials

Fish oil supplements fail to lower cardiovascular risk in diabetes

22 Nov 2018Registered users

Dietary supplementation with n-3 fatty acids (fish oils) in patients with diabetes is not associated with a reduction in cardiovascular events, a large randomised controlled study has found.  ‘These findings, together with results of earlier randomised trials involving patients with and those without diabetes, do not support the current recommendations for routine dietary supplementation with n-3 fatty acids to prevent vascular events,’ the study authors conclude.

 

Clinical reviews of research - by GPs with interest

Pre-eclampsia raises risk of vascular dementia later in life

22 Nov 2018Registered users

Women with a history of pre-eclampsia are three times more likely to develop vascular dementia later on, a Danish cohort study has found.

GP training programme improves HIV testing rates

22 Nov 2018Registered users

Sexual Health in Practice (SHIP), an educational programme tailored to general practice, increased GPs’ rates of HIV testing.

AF recurrence following catheter ablation more likely in obese patients

22 Nov 2018Registered users

Atrial fibrillation (AF) patients with a baseline BMI = 30 kg/m2 have a higher recurrence rate following catheter ablation, a  study of  an AF Ablation Long-Term Registry that included 104 centres across 27 European countries.

Risk factors for wheezing in early childhood across Europe

22 Nov 2018Registered users

Lower respiratory tract infections (LRTIs), maternal smoking, day care attendance and male gender are important risk factors for wheezing in infants, a panEuropean study has confirmed. Food allergy and infant feeding practices were not associated with wheeze. The prevalence of wheezing varied widely between different European countries.

 

HASLAM's view

Sharing information with patients will improve care

22 Nov 2018Registered users


Towards the end of my career as a frontline GP, I started providing my patients with printouts of their blood test results, along with a guide to what they meant. Perhaps I had been impressed by the vet who treated my Labrador, and who always did the same. It just struck me as odd that animal patients always seemed to be provided with more information than their human counterparts. The most that humans typically get is ‘Your blood test results were fine.’

 

CPD exercises associated with each issue

CPD exercise November 2018

22 Nov 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: • Managing mild to moderate asthma in adults • Diagnosing and managing cystic fibrosis in children • Managing complications of cystic fibrosis in adults

 

A hundred years ago

100 years ago: Neuroses in war and peace

22 Nov 2018Registered users

WITH THE END OF THE WAR an apt occasion is offered for a survey of work done, so that we may mobilize our ideas to attack the problem of neuroses in peace. Neuroses of war have been referred to by the term “shell-shock.” It is almost universally agreed by neurologists that this is a bad term, more borne in on us to-day, when shells are a thing of the past. Neuroses of war are essentially similar to the neuroses of peace, dependent on the same mechanisms and amenable to the same treatment. Three groups of cases seem to stand out: neuroasthenia; hysteria; and neuroses dependent on the occurrence of mental conflicts.

 

A hundred and fifty years ago

150 years ago: Generous diet in the treatment of nervous diseases

22 Nov 2018Registered users

THE UNAIDED EFFECTS OF FOOD may not have had the trial it deserves in the relief of nervous weakness. Patients are told to live well and adopt a generous diet, but this is usually judged by the amount of port wine or other alcoholic stimulant, rather than by bread, mutton or beef. If we inquire into the past history of nervous patients, we often find that for a considerable time the supply of food has been inadequate.