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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 stable angina in primary care

22 Oct 2018Registered users

Around 50% of people diagnosed with ischaemic heart disease present with stable angina as the first symptom. The likelihood of a diagnosis of angina increases with the number of cardiovascular risk factors present. A resting 12-lead ECG is recommended for all patients with suspected angina. However, a normal result does not exclude the presence of underlying coronary artery disease.

Tracking down and treating the cause of syncope

22 Oct 2018Registered users

Syncope is a transient loss of consciousness (T-LOC) caused by cerebral hypoperfusion, characterised by a rapid onset, short duration and spontaneous complete recovery. It needs to be differentiated from other conditions that can cause T-LOC such as seizures, trauma, hypoglycaemia, and psychogenic causes. Three principal types of syncope can be identified: reflex or neurally mediated, orthostatic hypotensive and cardiac. The common denominator of all these conditions is low systemic BP causing global cerebral hypoperfusion.

 

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.

 

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.

 

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. 

 

Women's health

Early treatment vital in pelvic inflammatory disease

23 Apr 2018Registered users

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.

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.

 

Paediatrics

Be vigilant for depression in children and adolescents

25 Jun 2018Registered users

The symptoms of depression in adolescents are similar to those in adults. Depression in children of primary school age may be very subtle and symptoms include mood fluctuations, tearfulness, frustration or temper tantrums. If depression is suspected, it is essential to evaluate the degree of risk. Risk has two key aspects: the likelihood of a potentially harmful incident occurring and degree of potential harm.

Treating nocturnal enuresis in children in primary care

21 Jun 2011Paid-up subscribers

Nocturnal enuresis is defined as involuntary wetting while asleep at least twice a week in children over the age of five. Primary nocturnal enuresis describes those children who have always been wet. Secondary nocturnal enuresis is defined as a relapse after a child has been completely dry for at least six months. Up to the age of nine years, nocturnal enuresis is twice as common in boys than girls but thereafter there is no sex difference in prevalence. At the age of five, 2% of children wet every night, and 1% are still wetting every night in their late teens. Bedwetting is not primarily caused by an underlying psychological disorder. However, psychological problems and life events can exacerbate or precipitate bedwetting in susceptible children who have a genetic basis for their condition.

 

Editorials

Combined oral contraceptive pill lowers ovarian cancer risk

22 Oct 2018Registered users

Women who use the combined oral contraceptive pill (COCP) are at reduced risk of developing ovarian cancer, a benefit that persists for several years after cessation, a nationwide cohort study from Denmark has found.

 

Clinical reviews of research - by GPs with interest

New antiplatelet agents are more effective in preventing recurrent MI

22 Oct 2018Registered users

Compared with clopidogrel, prasugrel and, in particular ticagrelor, led to a significant reduction in risk of recurrent fatal and non-fatal myocardial infarction (MI) in patients with acute coronary syndrome (ACS), in a study from France.

Intrauterine device use associated with reduced risk of cervical cancer

22 Oct 2018Registered users

Women who had used an intrauterine contraceptive device (IUD) were found to have a lower risk of cancer of the cervix in a systematic review and meta-analysis.

Breastfeeding may protect against recurrent cough in early adult life

22 Oct 2018Registered users

Longer duration of breastfeeding appears to reduce the risk of recurrent cough in young adults, a study from the United States has found. The researchers used data from the Tucson Children’s Respiratory Study, a large non-selected birth cohort in which infant feeding practices and adult health outcomes were ascertained prospectively.

High gluten intake in pregnancy associated with type 1 diabetes in offspring

22 Oct 2018Registered users

The findings of a cohort study from Denmark suggest that high dietary gluten intake by pregnant women may increase the risk of their children developing type 1 diabetes.

 

HASLAM's view

Why do patients consult phone-in doctors?

22 Oct 2018Registered users

She had been to her doctor, and her doctor hadn’t really seemed to understand what she had been concerned about and had told her to stop worrying, but she couldn’t. So I asked her to explain her symptoms, and with a sinking heart I began to recognise both the symptoms and the speaker. She was one of my own patients. The unsympathetic doctor she was describing was me. Obviously, the tinny sound coming from her radio must have disguised my voice, as she clearly had no idea it was me she was talking to.

 

CPD exercises associated with each issue

CPD exercise - October 2018

22 Oct 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: • Tracking down and treating the cause of syncope • Managing stable angina in primary care • Early recognition and prompt referral key in acute pancreatitis

 

A hundred and fifty years ago

150 years ago: Treatment of the insane without mechanical restraints

22 Oct 2018Registered users

CERTAIN WRITERS HINT DOUBTS of the value of the so-called non-restraint system in  English asylums, while others  advocate openly the use of the strait-waistcoat. They would have us give up a system of treatment which has been considered by English alienists to be the great merit of English asylums, has hitherto been zealously defended by them against the attacks of foreigners, and has now become so general, that there is hardly an asylum in this country in which a strait-waistcoat would be found. Henry Maudsley, M.D.

 

A hundred years ago

100 years ago: A twelve month pregnancy

22 Oct 2018Registered users

THE RECENT DECISION in the High Courts of Justice, in which the petitioner denied paternity of a child on the grounds of gestation being prolonged into ten months, lends peculiar piquancy to the following case which occurred quite recently in my own practice in which gestation lasted for 12 months.