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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.

 

Gastroenterology - Temporary access

Diagnosing and managing colorectal cancer

25 Jul 2018

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 2018

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.

Diagnosis and management of oesophageal cancer

22 Feb 2018

Oesophageal cancer commonly presents with dysphagia or odynophagia and can be associated with weight loss and vomiting. Referral for urgent endoscopy should always be considered in the presence of dysphagia regardless of previous history or medication. NICE recommends urgent referral (within 2 weeks) for direct access for upper GI endoscopy in patients with dysphagia and those aged 55 years or over with weight loss and any of the following: upper abdominal pain, reflux, or dyspepsia.

 

Symposium: Musculoskeletal medicine

Diagnosis and treatment of Sjögren’s syndrome

20 Dec 2018

Primary Sjögren’s syndrome is a chronic systemic immune-mediated condition of unknown aetiology characterised by focal lymphocytic infiltration of exocrine (mainly salivary and lacrimal) glands. It affects 0.1-4.6% of the European population and 90% of cases are female. Although it usually presents in the fifth or sixth decade, it can be seen in younger people who tend to present with systemic disease and are less likely to have classical sicca symptoms. Patients should be referred to a rheumatologist to confirm diagnosis, and this may involve scintigraphy/sialography and/or labial gland biopsy.

Managing low back pain in primary care

20 Dec 2018Registered users

Chronic low back pain is a common problem. Lifetime adult prevalence rates vary from 50 to 80%, and around a quarter of adults say they have experienced back pain during the past month. One in 40 report disabling back or neck pain. Each year around 7% of patients consult their GP with back pain. In 65-70% of primary care patients with low back pain there is no known pathoanatomical cause. Their pain is described as nonspecific and is postulated to arise from muscle strain or ligamentous injury. A further 15-20% of patients have mechanical low back pain with an identifiable cause such as degenerative disc or joint disease. 

 

Special reports

Improving outcomes for kidney transplantation

20 Dec 2018

Kidney transplantation is the optimum form of renal replacement therapy for suitable patients with end-stage renal disease. A successful transplant represents a much closer approximation to true renal replacement with excretion of waste products, regulation of electrolytes and other substances, than dialysis. The longer a recipient has been dialysis dependent before transplantation the poorer the outcome. Living donor transplantation is associated with better graft and patient survival than transplantation from a deceased donor. A genetic relationship with the recipient is not a prerequisite to becoming a living donor. Having a living donor offers the opportunity of pre-emptive transplant (i.e. avoidance of dialysis altogether).

Early recognition and prompt referral key in acute pancreatitis

22 Oct 2018

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.

GPs play a vital role in identifying and managing juvenile idiopathic arthritis

24 Sep 2018Registered users

Juvenile idiopathic arthritis (JIA) affects approximately 1-4 per 1,000 children under the age of 16. Girls are more commonly affected than boys. It is a heterogeneous condition, even within JIA categories, ranging from insidious arthritis affecting one to two joints to florid and life-threatening systemic arthritis. All patients with suspected JIA should be referred urgently to a specialist paediatric rheumatology team. Coordinated, multidisciplinary care within a specialist team is required to achieve optimal outcomes.

 

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 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.

 

Editorials

Smoking still the leading cause of preventable illness and early death

20 Dec 2018Registered users

A steady decline in cigarette smoking in adults between 1993 and 2017 and a decrease in the number of both men and women drinking at harmful levels between 2011 and 2017 are key findings from the Health Survey for England (HSE) 2017. Nevertheless, smoking remains the leading cause of preventable illness and premature death and alcohol remains a causal factor in numerous medical and mental health conditions, including cancer, cirrhosis, hypertension, depression, and accidents and injuries.

 

HASLAM's view

A handwritten message speaks volumes

20 Dec 2018Registered users

There is clearly something that most of us value in receiving a tangible written message. Many people get a real tingle of pleasure when an unexpected handwritten letter or card arrives in the post. I lose count of how many emails I receive each day, but none of these ever has the impact of a handwritten letter. I know it isn’t just me.

 

CPD exercises associated with each issue

CPD exercise - December 2018

20 Dec 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: • Diagnosis and treatment of Sjögren’s syndrome • Managing low back pain in primary care • Improving outcomes for kidney transplantation

 

Clinical reviews of research - by GPs with interest

High BP, smoking and diabetes are stronger predictors of MI in women than men

20 Dec 2018Registered users

Hypertension, smoking, especially heavy smoking, and both type 1 and type 2 diabetes are associated with a higher risk of myocardial infarction (MI) in women than men, a prospective population-based study has shown.

Consumption of nitrate-cured meat products increases odds of mania

20 Dec 2018Registered users

There is a strong and independent association between manic episodes and a history of eating nitrate-cured meat products, a US study has found.

Orgasm induced by non sexual behaviour

20 Dec 2018Registered users

Orgasm may be a neuropsychological process associated with diverse forms of stimulation, according to the findings of a study published in the International Journal of Sexual Health. The investigators analysed comments from 919 individuals who responded to an anonymous post in 2013 on the website PostSecret.com. The individual, unknown to the research team, described having an orgasm during exercise. The respondents posted comments about their own experiences of non genital/non sexual orgasms.

Obesity in early childhood leads to obesity in adolescence

20 Dec 2018Registered users

The vast majority of children who were obese at three years of age were overweight or obese in adolescence, a study from Germany has found.

Non invasive skin autofluorescence test shows promise

20 Dec 2018Registered users

An immunofluorescence test may be able to predict new onset diabetes, cardiovascular disease (CVD) and death, a study from the Netherlands has shown.

 

A hundred and fifty years ago

150 years ago: The place of wines in the diet of ordinary life.

20 Dec 2018Registered users

We add here a few words in correction of a statement which occurs in a former paper, and which, by ambiguity of phraseology, has led to misunderstanding and consequent cavil. We did not intend, when recommending the “hard-working student” to allow himself a bottle per diem of weak Bordeaux wine, to give that recommendation to young lads. We were thinking of “hard working students” of middle age; and we would state our very firm conviction, that for youths (say under 25) whose bodily frame is yet not fully consolidated, the proper rule is either no alcohol or very little indeed.

 

A hundred years ago

100 years ago: Blood pressure and psycho-neuroses

20 Dec 2018Registered users

In a pure neurasthenia, unless complicated by organic disease, the blood pressure is usually sub-normal. In a conversion hysteria, it is generally  normal. In an anxiety neurosis, it is more often considerably above the normal. If we are dealing now with young patients, and we find that their blood pressure is anything from 135 mm to 150 mm, we have strong reason for thinking that their condition is a pure anxiety-neurosis.