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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

Early detection of liver cancer key to improving outcomes

07 Aug 2019Paid-up subscribers

Liver cancer is the sixth most prevalent cancer and the third most common cause of cancer deaths worldwide with approximately 800,000 deaths globally per annum. Hepatocellular carcinoma (HCC), which arises from the liver cells, accounts for approximately 90% of liver cancer cases. Other primary liver cancers include intrahepatic cholangiocarcinomas (CC), arising from the bile ducts within the liver, which account for 9-10% of cases alongside rarer angiosarcomas and hepatoblastomas. HCC remains a challenge as it is commonly diagnosed late in its course, often in patients with other comorbidities, and only has limited treatment options leading to a poor five-year survival.

Optimising the treatment of inflammatory bowel disease

07 Aug 2019Paid-up subscribers

Inflammatory bowel disease (IBD) is a chronic inflammatory condition which runs a relapsing and remitting course. The aetiology remains unclear but is thought to involve genetic susceptibility, altered gut microbiota, changes in immunological response and environmental triggers. 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.

 

Special reports

Management of hypertensive disorders in pregnancy

07 Aug 2019Paid-up subscribers

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. Although secondary care services take the lead on pregnancies complicated by hypertensive disorders, GPs have an important role to play prior to, during, and after pregnancy.

Prompt detection vital in postpartum mood disorders

24 Jun 2019Registered users

Common mental health disorders affect around one in five women during pregnancy and the first year following childbirth. Depression and anxiety disorders are the most prevalent mental health disorders during this period as they are at other times of life. It is important to distinguish postnatal depression from baby blues, which is common and requires no treatment, although it is a potential risk factor for postnatal depression. Postpartum psychosis affects 1 in 1,000 women and can develop very quickly in the first two weeks postpartum, often requiring urgent admission to a specialised mother and baby unit. One in six women with bipolar disorder will develop postpartum psychosis. 

Managing urinary incontinence in women

22 May 2019Paid-up subscribers

A detailed patient history is key to the assessment of patients with urinary incontinence and to guiding initial investigation and management. Clinical examination should include abdominal palpation to assess for masses, including an enlarged bladder. Visual inspection of the perineum and vagina helps determine whether the patient may be hypo-oestrogenic and can confirm the presence and grading of pelvic organ prolapse. Digital vaginal examination enables detection of masses, and an assessment of pelvic floor muscle strength. Urinalysis should also be carried out. Most patients will have either stress, urgency, or mixed urinary incontinence.

 

CPD exercises associated with each issue

CPD exercise - June 2019

24 Jun 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: • Improving outcomes in allergic rhinitis in children • Managing common skin conditions in infants • Prompt detection vital in postpartum mood disorders

 

Lead clinical reviews of 2019

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.

Does intensive BP lowering reduce risk of dementia?

25 Mar 2019Registered users

Intensive blood pressure (BP) control reduces the risk of developing mild cognitive impairment, but not dementia, a US randomised trial has found.

 

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.

 

Sepsis

Diagnosing and managing sepsis in children

23 Jan 2018Registered users

The clinical features of sepsis are: fever; tachycardia, with no other explanation; tachypnoea, with no other explanation; leukocytosis or leucopenia. To meet the International Pediatric Sepsis Consensus Conference definition, a patient should have two of these features, one of which should be fever or abnormal white cell count, in the presence of infection. Every time a child who has symptoms or signs suggestive of infection is assessed, it is important to consider whether this could be sepsis. This may seem obvious in a child presenting with fever, but not all children with sepsis present with high fever or focal signs.

Have a high index of suspicion for sepsis in primary care

23 Oct 2017Registered users

The incidence of sepsis in the UK is estimated at 200,000 cases a year. Around 70% of cases of sepsis originate in the community. Most infections are self-limiting and can be managed outside hospital. However, patients with sepsis will deteriorate rapidly and each hour of delay to antibiotic administration is linked to decreased survival by 7.6%. Infants (< 1 year) and the elderly (> 75 years) seem to be far more likely to progress to sepsis than others. The assessment of sepsis in primary care should be standardised and include measurement of temperature, heart rate, respiratory rate, blood pressure, level of consciousness and oxygen saturation in young people and adults.

 

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 2016Paid-up subscribers

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.

 

Editorials

What is the optimal antidepressant dose?

07 Aug 2019Registered users

The optimal dose of a second-generation antidepressant lies towards the lower end of its licensed dose range, a systematic review and dose-response meta-analysis has found.

Direct oral anticoagulants reduce all-cause mortality in AF

24 Jun 2019Registered users

Direct oral anticoagulant (DOAC) therapy in patients with non-valvular atrial fibrillation (AF) was associated with a significantly lower risk of death compared with no anticoagulation, in a retrospective cohort study, published in Heart. In this cohort of newly diagnosed patients with moderate- to high-risk non-valvular AF treated in routine clinical practice, DOAC therapy was associated with a 31% reduction in all-cause mortality.

HRT may increase the risk of Alzheimer’s disease

22 May 2019Registered users

Postmenopausal women who take systemic hormone replacement therapy (HRT) are more likely to develop Alzheimer’s disease, although the increase in risk is modest, a Finnish nationwide case-control study has found.

 

Research reviews - by GPs with a special interest

Gabapentinoids may increase risk of suicidal behaviour in young patients

07 Aug 2019Paid-up subscribers

A large Swedish study has suggested that gabapentinoid medications are associated with an increased risk of suicidal behaviour and unintentional overdose in adolescents and young adults.

High levels of cardiorespiratory fitness associated with reduced risk of COPD

07 Aug 2019Paid-up subscribers

Good cardiorespiratory fitness in midlife may lower the risk of developing and dying from COPD, a prospective cohort study from Denmark has found.

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.

Benefits of quitting smoking outweigh the risks of weight gain

24 Jun 2019Paid-up subscribers

The cardiovascular and overall mortality benefits of stopping smoking far outweigh the risks of weight gain and acquiring type 2 diabetes, a study from the United States has shown.

 

HASLAM's view

Was I technically right but morally wrong?

24 Jun 2019Registered users

It’s a case that still bugs me. One that I honestly think I mishandled. Scientifically I was 100% correct. However, I still think I got it wrong. I believed myself to be a kind and compassionate doctor. I also knew and understood the science, and the importance of optimising my time. Would getting out of bed to drive to this patient, sitting with her for 20 minutes, being kind and understanding, have been the right thing to do?

 

A hundred and fifty years ago

150 years ago: Surgical practice during the siege of Paris

24 Jun 2019Registered users

During the Siege of Paris wounds were of exceptional gravity. Older surgeons, who had had much experience in wars, admitted that the wounds during the siege were of unexampled and unprecedented fatality. In cases I had observed a violent contusion of the marrow extending very high up; it was obvious to me that this marked injury was of immediate origin. At the same time, the bones themselves presented the most serious lesions; there was splitting and splintering of the bone, extending as high up as the great trochanter, for instance, in cases of fractured femur. Amputation was, at the beginning, universally employed. The results were disastrous, the mortality was absolute and general. Most strenuous exertions were made by Paris surgeons, and were much insisted on by myself, in the direction of conservative surgery in wounds which engaged the bones, and particularly the femur.

 

A hundred years ago

100 years ago: The mental condition preceding suicide

24 Jun 2019Registered users

The general practitioner  is often puzzled to know how to deal with a case in which suicide is frequently threatened,  but, provided his diagnosis of an anxiety neurosis is correct, it is probably better to treat these cases by psychotherapeutic methods, and take the slight risk of suicide than adopt such a course as warning and consequently scaring the relatives, or advising a constant attendant or admission to an institution, for such steps are often productive of more harm than good. On the other hand, in manic depressive conditions and paranoia, the risk of suicide is real and ever present. Too great watchfulness cannot be exercised, and such patients should only be sent to institutions for the treatment of mental diseases where the condition is fully understood and effective precautions are taken; for it is remarkable what cunning will be displayed, even by an apparently stuporous melancholic, to elude the vigilance of his attendants and seize an opportunity to kill himself.