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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

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.

Suspected cardiac syncope requires urgent investigation

27 Oct 2020Registered users

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.

 

Special reports

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.

 

Women's health -Temporary direct access

Investigating the cause of heavy menstrual bleeding

25 Mar 2019

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 2018

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.

Improving outcomes in allergic rhinitis in children

24 Jun 2019Paid-up subscribers

Allergic rhinitis can affect a child’s physical health, reduce their quality of life, sleep and concentration, and impact on school performance. Children with allergic rhinitis are at increased risk of developing asthma. Around 85% of those with asthma have allergic rhinitis, which can complicate diagnosis and management and also increase the risk of hospitalisation for asthma exacerbations. However, appropriate management of allergic rhinitis can improve asthma control. The diagnosis of allergic rhinitis can usually be made on the basis of the patient’s history and examination alone. 

 

Psychiatry

GPs have a pivotal role in bipolar disorder

25 May 2020Paid-up subscribers

Bipolar disorder is a complex, recurrent, severe and potentially lifelong mental illness. The peak age of onset is 15-19 years, with most cases developing before the age of 30. It is crucial to distinguish bipolar from unipolar depression not only as an essential starting point for appropriate treatment and risk management, but also to avoid antidepressant monotherapy which can exacerbate the frequency and severity of mood symptoms and cause resistance to appropriate medications.

Treating psychological trauma in the real world

23 Jan 2020Paid-up subscribers

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 2019Paid-up subscribers

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.

GPs are central to improving care of schizophrenia patients

20 Dec 2019Paid-up subscribers

Schizophrenia often runs a chronic course and is associated with considerable morbidity and mortality. While psychotic symptoms are the most obvious manifestations of the condition, negative symptoms (e.g. apathy and withdrawal) and cognitive symptoms (especially deficits in executive function) are often more disabling. It generally presents in late adolescence or early adulthood. Schizophrenia typically develops insidiously, potentially over several years. The GP is ideally placed to respond to family concerns, identify prodromal symptoms, screen for psychotic symptoms and initiate either a mental health review or active monitoring in primary care.

 

Editorials

Is opportunistic screening for AF in general practice worthwhile?

27 Oct 2020

Screening patients opportunistically in primary care does not improve detection of atrial fibrillation, compared with usual care, a cluster randomised controlled trial from the Netherlands has found.

Delirium linked to cognitive decline

24 Sep 2020

Delirium is associated with an increased risk of subsequent cognitive decline and there is evidence to suggest that the association is causal, a systematic review and meta-analysis has found. Every study found that those with delirium experienced greater cognitive decline than controls and the combined odds for a given cognitive decline were more than doubled in patients with delirium; OR 2.30. Subgroup analyses provided evidence that delirium is a causative factor rather than a marker of vulnerability to dementia.

 

Research reviews - by GPs with a special interest

Corticosteroid therapy for asthma raises risk of osteoporosis and fragility fractures

27 Oct 2020Registered users

Use of oral or inhaled corticosteroids appears to be an independent risk factor for osteoporosis and fragility fractures in patients with asthma, a UK population-based study has found.

Prediabetes associated with increased risk of CVD and all-cause mortality

27 Oct 2020Registered users

A meta-analysis has shown an association between prediabetes and raised risk of all-cause mortality and incident cardiovascular disease in the general population as well as patients with atherosclerotic heart disease.

 

HASLAM's view

How does memory work?

27 Oct 2020Registered users

If I could have my life as a GP all over again, and could be granted just one additional skill, it would be a much better ability to link faces and names.

 

A hundred and fifty years ago

Extracts from British and foreign journals - 1870

27 Oct 2020Registered users

Extraction of a pin from the urethra: M. Ticier reports a case in which a boy, aged 7,  introduced, at the encouragement of a school-fellow, a pin into his urethra. It slipped from his hand, and as usual retreated along the passage. 

A plan for reducing dislocation of the shoulder by Mr Lowe. 

On the therapeutic value of gastric juice: Signor Arturo Menzel supports the experiments and results of older experimenters in regard  to the value of gastric juice in cancerous tumours, and has collected a considerable number of cases in which it has been employed with advantage, either in true cancer or in lymphoma

 

A hundred years ago

Counter-irritation, by blister or percussion, in spinal therapeutics

27 Oct 2020Registered users

M.B., 22, had suffered from trench feet in January, 1916, for which he had been in hospital for six months. He applied for treatment last summer on account of pain in his feet describing his condition as if he were “walking on hot plates.” The pain would generally last for half an hour to four hours, though occasionally it might be present for a whole day. After a few séances of percussion of the seventh cervical spine, complete freedom from discomfort ensued.

 

Cancer - Temporary direct access

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.

Time to diagnosis key in improving lung cancer outcomes

25 Nov 2019

NICE recommends urgent referral via a suspected cancer referral pathway to the two week wait service if: chest X-ray findings suggest lung cancer or if patients aged 40 and over have unexplained haemoptysis. However, studies have indicated that around 20-25% of patients with confirmed lung cancer may have a chest X-ray reported as normal and this figure may be higher for early stage lung cancers. Therefore, the National Optimal Lung Cancer Pathway recommends that where there is a high suspicion of underlying malignancy (but the chest X-ray is normal), GPs should refer patients directly for a CT scan.