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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

Improving the management of chronic asthma in children

21 Dec 2020Registered users

There is no gold standard test to diagnose asthma. As a result, overdiagnosis and underdiagnosis are common especially when relying on history and clinical examination alone. Spirometry and bronchodilator reversibility testing are particularly useful when a child aged 5 years or older is brought to the practice with symptoms. The validated Asthma Control Test for children aged 12 years and over and the Children’s Asthma Control Test for children aged 4-11 years should be used to assess current asthma control based on four-week recall. Asthma control test scores correlate poorly with lung function and measures of airway inflammation such as FeNO in children and should not be used in isolation.

Diagnosis and management of malignant pleural mesothelioma

21 Dec 2020

Mesothelioma accounts for less than 1% of all cancers in England, Wales and Northern Ireland. There are almost 2,500 new diagnoses a year, of which 96% are pleural. The median age at diagnosis for malignant pleural mesothelioma (MPM) is 76 years. The majority of cases occur in men, most commonly following occupational exposure to asbestos. There is a latent period, usually 30-40 years, between exposure and disease development. A chest X-ray is usually the first-line investigation; 94% of patients with MPM have a unilateral pleural effusion, although the chest X-ray may be normal or show another asbestos-related lung disease. 

Diagnosis and management of Paget’s disease of bone

24 Nov 2020

Paget’s disease of bone is a metabolic disease in which focal abnormalities of bone remodelling occur in one or more skeletal sites. The affected bones enlarge and may become deformed and this can lead to complications including bone pain, pathological fractures, secondary osteoarthritis, deafness and nerve compression syndromes. The three main risk factors are age, male gender and family history. People with a first-degree relative with Paget’s disease have a seven-fold increased risk of developing the disease. Patients who have bone deformity or symptoms that might be due to Paget’s disease should be referred to secondary care. 

Treating to target will optimise long-term outcomes in RA

24 Nov 2020Registered users

Rheumatoid arthritis (RA) classically causes a symmetrical, small joint polyarthritis which left untreated can lead to joint destruction and deformity. NICE recommends that any adult with suspected persistent synovitis of undetermined cause should be referred for a specialist opinion. Patients should be referred urgently (even with a normal acute-phase response, negative anti-CCP antibodies or rheumatoid factor) if any of the following apply: the small joints of the hands or feet are affected; > 1 joint is affected; there has been a delay of = 3 months between onset of symptoms and seeking medical advice.

Suspected cardiac syncope requires urgent investigation

27 Oct 2020Paid-up subscribers

Around 40% of people experience a syncopal event during their lifetime. Cardiac syncope accounts for 10% of presentations. Incidence rises significantly with age. Assessment should be systematic: a thorough history, physical examination including lying and standing BP and 12-lead ECG. The medical history and physical examination are key. If following initial assessment cardiac syncope is suspected patients should be referred for urgent specialist cardiovascular assessment or emergency admission.

Diagnosis and management of abdominal aortic aneurysm

27 Oct 2020Registered users

Risk factors for abdominal aortic aneurysm formation include: smoking, increasing age, and family history. Men over the age of 65 are most commonly affected, with an abdominal aortic aneurysm present in approximately 1%. As the condition is normally asymptomatic, most patients have their aneurysms discovered through the screening programme or incidentally via other imaging investigations. Patients with a new diagnosis of an abdominal aortic aneurysm should be referred to their local vascular service.

 

Special reports

Psoriatic arthritis often goes unrecognised

21 Dec 2020Registered users

Psoriatic arthritis (PsA) is a seronegative systemic disease that belongs to the family of spondyloarthropathies. Its worldwide prevalence ranges from 0.05% to 1%, and it appears in 10-40% of patients with skin psoriasis; however, it is believed to be underdiagnosed. More than 80% of patients who are diagnosed with PsA already have skin disease, mainly in the form of plaque psoriasis. However, 15% of patients present with musculoskeletal involvement prior to psoriasis which makes the diagnosis of PsA challenging. It is important to do a thorough clinical assessment, take a family history and actively look for evidence of psoriasis: this includes examining nails, the scalp, intergluteal region and umbilicus.

Early symptom recognition key in management of TIA and stroke

24 Nov 2020Registered users

In the UK, at least 100,000 people have an acute stroke each year. A first ever transient ischaemic attack (TIA) affects around 50 people per 100,000 per year and around 15% of people who have a first stroke have had a preceding TIA. Patients with a suspected TIA should be referred immediately for specialist assessment and investigation, to be seen within 24 hours of onset of symptoms. Patients with a suspected stroke should be admitted immediately to hospital, ideally to an acute stroke unit. Patients with a suspected TIA who have a bleeding disorder or are taking an anticoagulant should also be admitted to an acute stroke unit as haemorrhage must be excluded.

Prompt diagnosis can improve outcomes in multiple sclerosis

27 Oct 2020Registered users

Multiple sclerosis (MS) is the leading cause of non-traumatic neurological disability in young adults. Between 1990 and 2016, the UK prevalence increased by 28%, due to earlier diagnosis and increased survival. The female to male ratio is 2:1, and patients have a minimally reduced life expectancy. Diagnostic criteria require that clinical, radiological and laboratory signs of MS are disseminated in both time and space. Diagnosis is based on a combination of features (relapses and clinical progression), MRI findings, and CSF analysis.

Optimising the management of diverticular disease

24 Sep 2020Registered users

Diverticular disease is characterised by intermittent abdominal pain in the left lower quadrant of the abdomen associated with constipation or diarrhoea. It can be difficult to differentiate from other conditions such as colitis, irritable bowel syndrome and colorectal cancer. Acute diverticulitis typically presents with severe constant left lower quadrant pain associated with signs of systemic upset such as fever. The patient may also have a change in bowel habit or rectal bleeding. On examination there is tenderness in the left lower quadrant. Acute diverticulitis may be complicated by perforation, abscess, fistula formation, bleeding or a stricture.

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.

Improving the detection and management of peanut allergy

25 May 2020Registered users

Peanut allergy currently affects around 2% of the population. It is the most common cause of fatal food related anaphylaxis. Most patients (80%) will have long-lived peanut allergy. Primary peanut allergy most commonly presents in the first 5 years of life after the first known exposure to peanut. Clinical features are those of an IgE-mediated reaction. All patients with a history suggestive of peanut allergy should be referred to an allergy clinic for comprehensive assessment and management.

 

Women's health

Investigating the cause of heavy menstrual bleeding

25 Mar 2019Registered users

Heavy menstrual bleeding has been defined as ‘excessive menstrual blood loss which interferes with a woman’s physical, social, emotional, and/or material quality of life’. Heavy menstrual bleeding affects 25% of women of reproductive age and is estimated to be the fourth most common reason for gynaecological referrals. Women should be asked about pelvic pain which might suggest endometriosis and pressure symptoms which might suggest significant fibroids. Examination is appropriate if there is intermenstrual or postcoital bleeding and, if the woman is actively bleeding, may identify the source of the bleeding.

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.

 

Paediatrics

Prompt treatment of impetigo reduces risk of spread

22 Jun 2020Paid-up subscribers

Impetigo is a common contagious bacterial infection of the skin. The causative organisms are either Staphylococcus aureus or, less commonly, Streptococcus pyogenes. The infection can occur at any age, but it is particularly common in children, especially the pre-school and early school age years, and tends to be more frequent during the summer months. It may arise on previously normal skin or complicate a pre-existing dermatosis. The diagnosis is essentially a clinical one, but if in doubt a swab should be taken for bacteriological culture.

Improving the detection and management of peanut allergy

25 May 2020Registered users

Peanut allergy currently affects around 2% of the population. It is the most common cause of fatal food related anaphylaxis. Most patients (80%) will have long-lived peanut allergy. Primary peanut allergy most commonly presents in the first 5 years of life after the first known exposure to peanut. Clinical features are those of an IgE-mediated reaction. All patients with a history suggestive of peanut allergy should be referred to an allergy clinic for comprehensive assessment and management.

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.

 

Cancer - Temporary direct access

Diagnosis and management of malignant pleural mesothelioma

21 Dec 2020

Mesothelioma accounts for less than 1% of all cancers in England, Wales and Northern Ireland. There are almost 2,500 new diagnoses a year, of which 96% are pleural. The median age at diagnosis for malignant pleural mesothelioma (MPM) is 76 years. The majority of cases occur in men, most commonly following occupational exposure to asbestos. There is a latent period, usually 30-40 years, between exposure and disease development. A chest X-ray is usually the first-line investigation; 94% of patients with MPM have a unilateral pleural effusion, although the chest X-ray may be normal or show another asbestos-related lung disease. 

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.

 

Psychiatry

Treating psychological trauma in the real world

23 Jan 2020

After a potentially traumatic event (PTE), many individuals experience either no distress or only transient distress, while others suffer considerable morbidity and may develop post-traumatic stress disorder (PTSD). Around one-third of people experiencing a PTE will develop PTSD, though this varies depending on the type of traumatic event and rates of PTSD are higher with type 2 trauma. Type 2 trauma involves repeated traumatic experiences over extended periods. Although PTSD symptoms can be present acutely, the diagnosis requires the persistence of symptoms for at least one month and the symptoms should cause functional impairment.

Early intervention key in first episode psychosis

20 Dec 2019

Psychosis is a state of mind in which a person loses contact with reality in at least one important respect while not intoxicated with, or withdrawing from, alcohol or drugs, and while not affected by an acute physical illness that better accounts for the symptoms. Common positive symptoms of psychosis include delusions and hallucinations. These symptoms are strongly influenced by the underlying cause of the psychosis: delusions in schizophrenia tend to be bizarre; delusions in depression negative; delusions in mania expansive. When a patient presents with psychotic symptoms, it is important to take a full psychiatric history, perform a mental state examination and complete relevant investigations, as indicated in each individual case.

 

Special reports

  
 

Editorials

Smaller bottle sizes may slow drinking and lower alcohol consumption

21 Dec 2020Registered users

Consuming wine at home from 50 cl bottles, compared with 75 cl bottles, may reduce both the amount of alcohol consumed and the rate of consumption, a study from the UK has found.

Cardiovascular risk assessment vital in patients with rheumatoid arthritis

24 Nov 2020Registered users

Patients with rheumatoid arthritis (RA) have an excess of stroke and heart failure which appears to accumulate in the five years before diagnosis, an English population-based study has found. The excess risk for further cardiovascular disease (CVD) events persisted after diagnosis and was not totally explained by differences in traditional CVD risk factors or RA-related risk factors at diagnosis.

 

HASLAM's view

Every life lost is a tragedy

21 Dec 2020Registered users

I doubt if any of us will be sad to wave goodbye to 2020. When we look back on our lives, this will certainly be one year that will be truly memorable unlike no other. Hidden in all those horrific morbidity and mortality statistics have been tens of thousands of individual tragedies. When deaths appear in large numbers the personal stories can become blurred. Each death is a pixel, part of a greater national picture, but also an entire portrait in itself.

 

Research reviews - by GPs with a special interest

Loneliness associated with increased risk of type 2 diabetes

21 Dec 2020

A study based on the English Longitudinal Study of Ageing (ELSA) suggests that loneliness is an independent risk factor for diabetes.

Can a hot bath a day keep the cardiologist away?

21 Dec 2020Registered users

Taking a hot bath every day or most days may lower the risk of cardiovascular disease (CVD), a study from Japan has suggested.

Relationship structure and sexual health

21 Dec 2020Registered users

Consensually nonmonogamous partnerships, including open relationships, comprise a substantial proportion of sexual relationships in the USA, a national population-based survey has concluded. It is important to be non-judgemental when eliciting sexual histories, to discuss risks and offer the right tests to the right people to minimise STI/HIV transmission.

HPV vaccination lowers risk of invasive cervical cancer

24 Nov 2020Registered users

Introduction of the quadrivalent human papilloma virus (HPV) vaccination programme in girls and young women in Sweden has led to a substantially reduced risk of invasive cervical cancer at population level, a national study has shown.

Smokers’ dependence on cigarettes has decreased over the past decade

24 Nov 2020Registered users

Between 2008 and 2017 smokers appear to have become less dependent on cigarettes but also less likely to try to quit or cut down. For those who tried to quit, fewer used behavioural support and more used pharmacological support, a study has found.

Long-term PPI use associated with increased risk of type 2 diabetes

24 Nov 2020Registered users

Regular use of proton pump inhibitors (PPIs) increased the risk of type 2 diabetes in a cohort analysis of three large American population studies. The risk increased with longer duration of use.

 

A hundred years ago

100 years ago: Dislocations of the jaw and hip

24 Nov 2020Registered users

It was now about 7 a.m. there was a sweet shop next door, and it was shuttlecock season. I went in and bought a wooden battledore, sawed off the end, hollowed it out with a knife, cut down the sides to the right width, placed it on the woman’s teeth, which were, fortunately, pretty sound, kept it there firmly by pressing the palm of my right hand under the chin, put the end of the handle on my left shoulder, grasped the middle with my left hand, and was delighted to find that I had leverage enough and to spare for easy replacement.

 

A hundred and fifty years ago

150 years ago: Chloral therapy in delirium tremens

21 Dec 2020Registered users

A clergyman, aged 40, has been a drunkard for years, but worse since his marriage three and a half years ago to a woman beneath him in station, and with whom he does not seem to have got on well.  He has been in the habit of taking all kinds of drinks and has had delirium tremens several times, the last bad attack being a little more than a year ago. Sometimes he has gone for six months without taking any drink. His father died of paralysis from disease of the brain. The history of insanity is uncertain.