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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

Optimising the management of neuropathic pain

25 Sep 2019Registered users

Neuropathic pain is defined as ‘pain that is caused by a lesion or disease of the somatosensory nervous system.’ The International Association for the Study of Pain (IASP) pain grading system is a simple way of determining the likelihood of a neuropathic component. If the history suggests a relevant neurological lesion or disease and the patient describes pain in an anatomically plausible distribution of a nerve, neuropathic pain is ‘possible’; it is ‘probable’ if there are corresponding examination findings in that same distribution and ‘definite’ if there is a confirmatory diagnostic test. 

Early detection of liver cancer key to improving outcomes

07 Aug 2019Registered users

Hepatocellular carcinoma (HCC) accounts for around 90% of liver cancer cases and intrahepatic cholangiocarcinoma (CC) for 9-10%. Most cases of HCC occur in the context of chronic liver disease with cirrhosis, particularly in those with chronic hepatitis B or C. Other major risk factors include excessive alcohol consumption, obesity and aflatoxins. Overall, 10-15% of cirrhotic patients will develop HCC within 20 years. Patients presenting with an upper abdominal mass consistent with an enlarged liver should be referred for an urgent direct access ultrasound scan within two weeks. 

Optimising the treatment of inflammatory bowel disease

07 Aug 2019Registered users

Inflammatory bowel disease (IBD) is a chronic inflammatory condition which runs a relapsing and remitting course. Ulcerative colitis (UC) is more common than Crohn’s disease (CD). UC almost always affects the rectum and extends proximally and continuously to the colon to a variable extent. CD most commonly affects the terminal ileum or colon but can affect any part of the gastrointestinal tract from the mouth to the anus. The vast majority (90%) of people with UC report bloody stools compared with less than 50% of those with CD. CD is characterised by a triad of abdominal pain, diarrhoea and weight loss.

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. 

Managing common skin conditions in infants

24 Jun 2019Paid-up subscribers

Atopic eczema, or atopic dermatitis, affects up to 20% of children and often presents in infancy. Cow’s milk allergy can also manifest as eczema and gastrointestinal (GI) symptoms. Food allergy should be suspected if there is a clear history of a reaction to a food in infants with moderate to severe eczema not responding to standard treatment, in infants with very early onset eczema (under 3 months) and those with GI symptoms. Seborrhoeic dermatitis is often an early manifestation of atopic eczema. Naevus simplex is a common congenital capillary malformation occurring in up to 40% of newborns. Port wine stains are less common, affecting about 0.3% of infants. 

Optimising the management of systemic lupus erythematosus

22 May 2019Paid-up subscribers

Systemic lupus erythematosus (SLE) is a multisystem, autoimmune disease. SLE mainly affects women and causes fatigue, rashes (often associated with photosensitivity), hair loss and inflammatory arthritis. However, it can also affect men in whom it is often more severe with a greater likelihood of renal involvement and a greater degree of organ damage. According to the British Society for Rheumatology guideline, the diagnosis of SLE requires a combination of clinical features and the presence of at least one relevant immunological abnormality.

 

Special reports

Holistic assessment key in hidradenitis suppurativa

25 Sep 2019Registered users

Hidradenitis suppurativa is a chronic inflammatory skin disease which can develop from puberty onwards, with painful, deep-seated inflamed lesions at characteristic sites. It is much more common in smokers. There is also a clear link with obesity. Patients complain of recurring painful boils in one or more of the typical areas. In women the most common areas affected are under the arms, under the breasts, in the groin, medial thighs, or suprapubic area and in men the armpits, buttocks and perianal area. Hidradenitis suppurativa is diagnosed on history and clinical appearance.

Diagnosing and managing dementia in primary care

25 Sep 2019Registered users

In patients with suspected dementia, the history should cover cognitive, behavioural and psychological symptoms, and the impact symptoms have on daily life. A physical examination is necessary to look for any focal neurological signs and to exclude any visual or auditory problems. Baseline blood tests should be carried out. A medication review should be undertaken as many commonly prescribed drugs have anticholinergic effects which can exacerbate cognitive impairment. A brief cognitive screening test should be performed before referral to a memory clinic.

Management of hypertensive disorders in pregnancy

07 Aug 2019Registered users

Hypertension is the most common medical complication of pregnancy, affecting 8-10% of pregnancies in the UK. It is associated with risks to both the woman and the fetus, with increased risks of pre-eclampsia, preterm delivery, fetal growth restriction, placental abruption and perinatal death. Any new onset of hypertension after 20 weeks or symptoms or signs suspicious of pre-eclampsia should be referred for same day assessment at a secondary care antenatal assessment unit.

 

CPD exercises associated with each issue

CPD exercise - September 2019

25 Sep 2019Paid-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: • Optimising the management of neuropathic pain • Diagnosing and managing dementia in primary care • Holistic assessment key in hidradenitis suppurativa

 

Dermatology

Pruritus may be a symptom of underlying systemic disease

22 Mar 2018Paid-up subscribers

Itch is a common symptom of many dermatological conditions (e.g. eczema, urticaria and lichen planus) but can also be a manifestation of underlying systemic, neurological and psychological disorders, or an adverse reaction to medication. The assessment of patients with generalised itch but no rash requires a detailed history and examination to narrow the spectrum of potential causes. Examination should include inspection of the entire skin. Physical examination should include palpation for lymphadenopathy and organomegaly.

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.

 

Post traumatic stress disorder

Identifying patients with complex PTSD

01 Aug 2016Registered users

Type 2 or complex trauma results from multiple or repeated traumatic events occurring over extended periods. Complex trauma is often associated with other adversity and stressors such as neglect, loss or deprivation. For many individuals these traumas occur at a developmentally vulnerable time with the perpetrator often in a caregiving role. Patients who have experienced complex trauma should be assessed for the core symptoms of PTSD. In addition, patients should be assessed for disturbances in the three domains of emotional dysregulation, negative self-concept and interpersonal disturbances.

Be vigilant for post-traumatic stress reactions

23 May 2016Registered users

The diagnosis of post-traumatic stress disorder (PTSD) differs from most psychiatric disorders as it includes an aetiological factor, the traumatic event, as a core criterion. The DSM 5 core symptoms of PTSD are grouped into four key symptom clusters: re-experiencing, avoidance, negative cognitions and mood, and arousal. Symptoms must be present for at least one month and cause functional impairment.

 

Neurology

Diagnosis and management of sleep-related epilepsy in adults

24 Sep 2018Registered users

Nocturnal epilepsies account for 10-15% of all epilepsies, and 80% of nocturnal epilepsies in adults are focal. They present a diagnostic challenge as they can be difficult to differentiate from normal movements and behaviour during sleep and also from several non-epileptic, sleep-related, motor and behavioural disorders. More than 90% of the seizures in sleep-related hypermotor epilepsy (SHE) occur during sleep. Seizures in SHE are simple partial seizures which easily wake the patient so that they will usually be able to recall the seizures, often describing auras of somatic sensations or feeling unable to breathe. SHE seizures have a rapid onset and offset, a short duration (usually < 2 min), and a stereotyped motor pattern for that individual.

 

Editorials

Childhood asthma peaks at the start of the school year

09 Oct 2019Registered users

Asthma exacerbations increase in children under 15 years, especially boys, when children return to school in September after the summer holidays, a UK study has found. The adjusted daily rate of GP in-hours asthma consultations in children was 2.5 to 3 times higher in the back to school excess period than in the baseline period.

 

Research reviews - by GPs with a special interest

Bundle branch block an indicator of heart failure risk

25 Sep 2019Paid-up subscribers

Opportunistic finding of bundle branch block (BBB) in primary care patients without major cardiovascular disease should be considered a warning of future heart failure, a retrospective cohort study from Denmark concludes.

Many smokers and former smokers have misconceptions about nicotine

25 Sep 2019Paid-up subscribers

Nearly 40% of smokers and former smokers believe it is the nicotine in cigarettes that causes cancer, a UK study has found.

Omega-3 fatty acid supplements do not prevent or improve type 2 diabetes

25 Sep 2019Paid-up subscribers

Supplementary long chain polyunsaturated fatty acids (PUFA) such as omega-3 have no effect on the prevention of diabetes or on glucose metabolism, a large meta-analysis commissioned by the World Health Organization (WHO) has found.

 

A hundred and fifty years ago

150 years ago: Spectral illusions due to physical disorder

25 Sep 2019Registered users

An old widow woman, living in a retired village, came one day to the parson of the parish in a state of great despondency. She said she had had 'a signal warning,' and she was sure she would soon be in her grave, for she was continually haunted by 'a skeleton'. The parson having in vain tried to convince her that she was under a delusion, set about a systematic examination of her eyes.

 

A hundred years ago

100 years ago: Incontinence cured by electrical methods

25 Sep 2019Registered users

About this time, it occurred to me that in children enuresis often ceases spontaneously about puberty – i.e., among other things coincidentally in the development of the prostate. I determined to stimulate this organ electrically in incontinent young men and chose a high-frequency condenser electrode for the purpose. It consisted of a small test tube, filled with water, and corked. Through the cork was thrust a stiff wire, having a loop on the outside for attachment to the lead from the solenoid. The test tube was vaselined and introduced about 2 to 3 inches into the rectum. It was then connected with the generator, and the high-frequency current turned on for 15 minutes. The treatment was given daily. An improvement in results was very soon evident. Cures rose from 25 to 60 per cent

 

HASLAM's view

Should GPs moan about their patients?

25 Sep 2019Registered users

Writing anonymised stories is fine, fascinating, and can be immensely entertaining and instructive. But moaning about your patients? After all, both you and I are also patients.

 

Lead research reviews of 2019

Antiretroviral treatment in gay men minimises risk of HIV transmission

24 Jun 2019Registered users

There is effectively zero risk of HIV transmission in gay men through condomless sex when HIV viral load is adequately suppressed, the findings of the PARTNER2 study, published in the Lancet, suggest.

Do 5 alpha-reductase inhibitors raise the risk of type 2 diabetes?

22 May 2019Registered users

Finasteride and dutasteride appear to be associated with a modest increase in the risk of developing type 2 diabetes, according to the findings of a retrospective cohort study.

Regular cannabis use raises risk of psychosis

24 Apr 2019Registered users

Daily cannabis use is associated with a three-fold increased risk of psychotic disorder, a multicentre, international case-control study has shown.