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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

Prompt treatment of impetigo reduces risk of spread

22 Jun 2020Registered users

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.

Diagnostic assessment key in autism spectrum disorder

22 Jun 2020Registered users

Autism spectrum disorder (ASD) is a complex pervasive neurodevelopmental disorder with an estimated lifetime prevalence of 1%. ASD presents across a wide range of intellectual ability and persists throughout life. Core symptoms include abnormal social interaction and communication, restricted and repetitive interests or activities, associated with lack of cognitive flexibility, and unusual sensory responses. ASD is highly heritable and polygenic. The male:female ratio of ASD is 3:1. Although the behavioural presentation has a childhood onset, approximately 40% of children with ASD are undiagnosed.

GPs have a pivotal role in bipolar disorder

25 May 2020Registered users

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.

Diagnosis and treatment of obsessive compulsive disorder

25 May 2020Registered users

Obsessive compulsive disorder (OCD) consists of obsessions (repetitive, intrusive thoughts, urges, impulses or doubts) and compulsions (ritualistic, deliberate behaviours performed in response to obsessions). As well as contamination and safety fears, many patients experience distressing thoughts of causing harm. Sexual obsessions are common, including thoughts regarding sexual orientation, aggressive sexual behaviour or child molestation. Typical compulsions include checking, washing, ruminating, and counting.

Managing bothersome LUTS

23 Apr 2020Registered users

Lower urinary tract symptoms (LUTS) in men can be defined by clinical symptoms arising from the bladder, bladder neck, urethral sphincter, urethra or prostate. Benign prostatic hyperplasia (BPH) is the most common cause of LUTS. By 80 years of age almost 90% of men have developed BPH at varying symptomatic levels. If the patient’s symptoms and examination findings are suspicious of cancer then an urgent two week wait referral should be made to urology. Other reasons for referral include: complicated LUTS with recurrent or persistent UTI, retention, renal impairment, stress incontinence or bothersome LUTS not resolved by conservative or drug management.

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.

 

Special reports

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.

 

Research reviews - by GPs with a special interest

Healthy lifestyle associated with longer life expectancy free of diabetes

22 Jun 2020Paid-up subscribers

A large cohort study has demonstrated that a healthy lifestyle in midlife can increase life expectancy free of type 2 diabetes, as well as cardiovascular disease (CVD) and cancer.

Siblings of infants with sudden unexpected death at increased risk

22 Jun 2020Paid-up subscribers

An observational study using clinical case records has found a ten-fold increased risk of sudden unexpected death in infancy (SUDI) in siblings of SUDI cases.

Primary care intervention increases uptake of HCV testing

22 Jun 2020Paid-up subscribers

An electronic algorithm integrated with primary care clinical database systems achieved a modest increase in hepatitis C (HCV) case finding, a UK general practice-based study has found.

E-cigarette pilot study helps smokers quit

22 Jun 2020Paid-up subscribers

More than a third of smokers who completed a pilot study of e-cigarettes as a smoking cessation aid quit smoking.

 

Cancer - Open 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.

 

Paediatrics

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.

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. 

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.

 

Women's health

Have a high index of suspicion for ectopic pregnancy

24 Mar 2020Registered users

Ectopic pregnancy is estimated to occur in 1-2% of all pregnancies and continues to be the leading cause of maternal mortality in early pregnancy. Most ectopic pregnancies are located within the fallopian tube and carry a risk of tubal rupture and intra-abdominal bleeding. Women with ectopic pregnancy can present in a wide variety of ways, from acute collapse following rupture to asymptomatic and unaware that they are pregnant. Symptoms may include vaginal bleeding and abdominal pain. There may also be non-specific symptoms such as Gl and urinary symptoms, rectal pressure, dizziness, shoulder tip pain, fainting or syncope. 

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. 

 

Editorials

Inactivity and depression in adolescence

22 Jun 2020Registered users

Sedentary behaviour during adolescence is associated with an increased risk of depressive symptoms at the age of 18, a UK study has found. Healthcare practitioners should ensure that parents and carers are aware of government advice on how much physical activity children and young people should be doing (i.e. at least 60 minutes of moderate-vigorous activity per day). Adolescents should be routinely asked about physical activity and sedentary behaviour levels, and every opportunity taken to emphasise the mental health benefits of physical activity.

Perinatal depression linked to psychosis in offspring

25 May 2020Registered users

The children of mothers who experience perinatal depression are more likely to report psychotic experiences at the age of 18, a UK prospective cohort study has found. A joint analysis found an association between maternal antenatal depression symptoms and both offspring psychotic experiences and depression at age 18. Most of those with psychotic symptoms will not go on to develop psychosis or schizophrenia. However, they are still at increased risk of low educational and occupational achievement, social impairment, harmful drinking and substance misuse.

 

HASLAM's view

Is there a cure for loneliness?

22 Jun 2020Registered users

Loneliness really does matter, as so many people in this era of lockdown in the Covid-19 pandemic will personally confirm. Lonely people are more likely to visit their GP, have higher use of medication, higher incidence of falls and increased risk factors for long-term care. Loneliness is a serious problem. However, if anything demonstrates the potential overmedicalisation of society it must be the concept of prescribing medication to ease loneliness.

What does your consulting room say about you?

25 May 2020Registered users

Of all the remarkable changes that Covid-19 has brought into our lives, one of the most intriguing has been the dramatic increase in the use of video calls and video conferencing. Don’t tell me that I’m not the only one who spends on-line meetings examining the walls and bookshelves in participants’ rooms. What does your consulting room – real or virtual – say about you? It might be worth checking….

 

A hundred years ago

100 years ago: Use and abuse of psychoanalysis

22 Jun 2020Registered users

Doctors have done little to discourage the entry of the unskilled into becoming practitioners of psychoanalysis, a field which belongs to the trained physician. Unqualified practitioners abound both here and in America. Some medical men have encouraged lay efforts and are apt to express contempt for those who believe that mental ills may supervene on physical infirmities, or may be but evidence of a disorganized function.

100 years ago: Influenza pandemic and public health

25 May 2020Registered users

The pandemic of influenza that has during the last 12 months swept over the world started in China or Russia, where it is endemic, became epidemic, spreading to neighbouring countries along the ordinary channels of human intercourse, and from persons to persons, and finally took on pandemic proportions, passing over the whole world. The seriousness of the disease is shown by the mortality returns, which were  enormously increased everywhere.

 

A hundred and fifty years ago

150 years ago: Insanity and general debility

22 Jun 2020Registered users

IN 83 OF THE LAST 100 cases in my case book for the asylum, whose disease was under six months’ duration, there were symptoms of bodily disorder that could be directly connected with the psychical symptoms. One bodily disorder accompanying insanity I call ‘general debility’(13 of the 100 cases). There is great emaciation, no vigour or ability for bodily exertion, languor, and a sense of prostration. The mental symptoms in these cases are generally those of melancholy and depression of mind. There is often a sluggishness in the performance of even the organic bodily functions – a slow pulse, costive bowels, a weak circulation in the extremities, with cold feet, blue hands, and pinched features. This is without organic disease of any kind.

150 years ago: Senile delirium: treatment

25 May 2020Registered users

I have reported cases in The Practitioner of several old persons who have died while labouring under senile delirium, all of which were attended by excessive talking that would continue hour after hour, and day after day, exhausting themselves such that they effectually talked themselves to death. It occurred to me to consider whether the cerebral symptoms of senile delirium could be traceable to a derangement of liver function. I had not long to wait before testing the value of this idea on a case. I confess to having some anxiety as to the result.

 

Men's health

Managing bothersome LUTS

23 Apr 2020Registered users

Lower urinary tract symptoms (LUTS) in men can be defined by clinical symptoms arising from the bladder, bladder neck, urethral sphincter, urethra or prostate. Benign prostatic hyperplasia (BPH) is the most common cause of LUTS. By 80 years of age almost 90% of men have developed BPH at varying symptomatic levels. If the patient’s symptoms and examination findings are suspicious of cancer then an urgent two week wait referral should be made to urology. Other reasons for referral include: complicated LUTS with recurrent or persistent UTI, retention, renal impairment, stress incontinence or bothersome LUTS not resolved by conservative or drug management.

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.