The Practitioner - 1868-2018: Supporting general practitioners for 150 years
 
 
 
 
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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.

 

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.

 

Special reports

History taking the key to diagnosing food allergy in children

25 Jul 2018Registered users

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.



 

Care of the Elderly

Tailor BP targets to the older patient with hypertension

25 Jun 2018

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. 

Timely diagnosis of vascular dementia key to management

23 Jan 2018

Vascular dementia is the second most common type of dementia, after Alzheimer’s disease, and accounts for 15% of cases. The core diagnostic features include cognitive impairment in at least two domains (orientation, attention, language, visuospatial function, executive function, motor control and praxis), which affect social or occupational function, together with evidence of cerebrovascular disease (focal neurological signs or neuroimaging). Crucially there should be a temporal relationship between cerebrovascular disease and the onset of cognitive changes.

Pulmonary rehabilitation improves exercise capacity and quality of life

23 Jan 2018

Pulmonary rehabilitation is a multifaceted programme of exercise and education that aims to improve breathlessness, exercise capacity, and quality of life, and aid self-management. Patients with chronic respiratory failure, those on long-term or ambulatory oxygen and patients with anxiety and depression can all benefit from rehabilitation. It is one of the most beneficial and cost-effective treatments for COPD and should be considered a fundamental component of disease management rather than an option.

Frailty predicts adverse outcomes in older people with diabetes

23 Jan 2017

In older people living with diabetes, geriatric syndromes, which indicate frailty, are emerging as a third category of complications in addition to the traditional microvascular and macrovascular sequelae. Frailty is defined by the presence of three or more phenotypes (weight loss, weakness, decreased physical activity, exhaustion and slow gait speed). Patients may progress from a non-frail to pre-frail or frail state. With timely intervention, there is a greater chance of an individual recovering from pre-frail to non-frail than deteriorating into frailty.

Controlling joint pain in older people

25 Jan 2016

The prevalence of chronic pain in older people in the community ranges from 25 to 76% and for those in residential care, it is even higher at 83 to 93%. The most common sites affected are the back, hip, or knee, and other joints. There is increased reporting of pain in women (79%) compared with men (53%). Common conditions include osteoarthritis and, to a lesser extent, the inflammatory arthropathies such as rheumatoid arthritis. The differential diagnosis includes non-articular pain such as vascular limb pain and nocturnal cramp, some neuropathic pain conditions (such as compressive neuropathies and postherpetic neuralgia), soft tissue disorders such as fibromyalgia and myofascial pain syndromes. 

 

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.

Raised resting heart rate associated with increased mortality risk

25 Jul 2018Registered users

A high resting heart rate and an increase in resting heart rate over a decade are associated with a greater risk of death from cancer and other causes as well as cardiovascular disease (CVD), a study from Australia has found.

 

Dermatology

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.

Managing actinic keratosis in primary care

24 Oct 2016Registered users

Actinic, or solar, keratosis is caused by chronic ultraviolet-induced damage to the epidermis. In the UK, 15-23% of individuals have actinic keratosis lesions. Dermatoscopy can be helpful in excluding signs of basal cell carcinoma when actinic keratosis is non-keratotic. It is always important to consider the possibility of squamous cell carcinoma. The principal indication for referral to secondary care is the possibility of cutaneous malignancy. However, widespread and severe actinic damage in immunosuppressed patients also warrants referral.

 

Editorials

Anticholinergic drugs and risk of dementia

25 Jul 2018Registered users

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.'

 

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

 

Photoguide selection - with PubMed links

Sun damage

23 Jun 2016

 • Squamous cell carcinoma • Actinic keratosis horn • Bowen’s disease • Solar elastosis • Rosacea • Discoid lupus

Allergic reactions

24 Sep 2015

• Fixed drug eruption • Fabric plaster reaction • Latex allergy • Morbilliform drug reaction • Allergic conjunctivitis • Anaphylaxis

Urgent referrals

23 Mar 2011

• Eczema herpeticum • Pemphigus vulgaris • Perinephric abscess • Quinsy [with pre-set links to the evidence base]

 

A hundred and fifty years ago

A hundred and fifty 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. ...

 

A hundred years ago

A hundred years ago: Masturbation

25 Jul 2018Registered users

Three factors – a long prepuce, slight urethritis, and highly sensitive nature of the part (increased by constant irritation, naturally and unnaturally) – have a great bearing on the continuance of the obnoxious practice. Another factor in many cases consists in the perusal of literature that is suggestive and sometimes even pornographic. French novels, which merely relate travesties of love and deal with the ‘sublime passion’ in gross and vulgar fashion are avidly read by these patients, just that their sensitive imaginations may be stimulated by the suggestive descriptions and hardly veiled innuendoes.