The Practitioner[JOURNAL]
Sun
200 papers
MP-MRI could improve the diagnosis of prostate cancer.
Rees J
Practitioner · 2017 Feb · PMID 29020718
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Ulnar nerve injury on removal of a contraceptive implant.
O'Grady EE, Power DM
Practitioner · 2016 Dec · PMID 29020717
The close proximity of contraceptive implant placement to the course of the ulnar nerve can result in injury. Several factors have been implicated in this complication including: low BMI, erroneous placement of the impla...
The close proximity of contraceptive implant placement to the course of the ulnar nerve can result in injury. Several factors have been implicated in this complication including: low BMI, erroneous placement of the implant, implantation over the brachial groove, and migration of the implant from its original insertion. Clinicians should familiarise themselves with the vulnerable neurovascular structures in the area and refer promptly to a specialist if any neurological symptoms develop during placement or removal of these devices. The prognosis following nerve injury is related to the anatomical site, pathophysiological depth of injury and delay between injury and treatment. Minor injury (neurapraxia) results from ischaemia or oedema within the nerve. In more severe injuries there is axonal damage resulting in Wallerian degeneration. The axonal damage affects all nerve fibre subtypes and as a result there is usually neuropathic pain and loss of autonomic sudomotor and vasomotor function in the cutaneous territory of the affected nerve. Loss of these autonomic supplies results in disruption of function of sweat glands and blood flow regulation which manifests as dry erythematous skin. High-grade nerve injury with axonal degeneration should be suspected when there is neuropathic pain, autonomic dysfunction and a positive Tinel’s sign (pain in the territory of the nerve elicited by gently tapping over the site of suspected injury). The British Orthopaedic Association recommends prompt referral for specialist assessment when there is motor or sensory dysfunction in the territory of a nerve following an intervention in proximity to the nerve. Early recognition and intervention may prevent further degeneration and improve outcomes.
Improving joint pain and function in osteoarthritis.
Owens C, Conaghan PG
Practitioner · 2016 Dec · PMID 29020716
Osteoarthritis has become a major chronic pain condition. It affects more than 10% of adults and accounts for almost 10% of health service resources. The impact of osteoarthritis is amplified by underuse of effective mus...
Osteoarthritis has become a major chronic pain condition. It affects more than 10% of adults and accounts for almost 10% of health service resources. The impact of osteoarthritis is amplified by underuse of effective muscle strengthening exercises and a focus on often less effective and poorly tolerated analgesic therapies. Although traditionally considered to be primarily a disease of cartilage, there is now ample evidence that typical clinical osteoarthritis involves multiple tissue pathologies. Increased BMI is associated with a higher incidence of knee osteoarthritis. Anatomical abnormalities such as valgus alignment or previous joint trauma including meniscectomy, anterior cruciate ligament rupture and fracture through the joint are also associated with increased incidence of osteoarthritis. Pain is the main presenting symptom. However, we still have a poor understanding of the causes of pain in osteoarthritis. In patients aged 45 or over the diagnosis should be made clinically without investigations if the patient has activity-related joint pain in addition to early morning joint stiffness lasting less than 30 minutes. Muscle strengthening and aerobic exercise have been shown to improve joint pain and function. Weight loss not only improves joint pain and function but has a myriad of other health benefits, reducing the incidence of lifestyle associated diseases such as cardiovascular disease and type 2 diabetes, and mechanical stress on the joints.
Diagnosis and management of polymyalgia rheumatica.
Jones O, Birrell F
Practitioner · 2016 Dec · PMID 29020715
Polymyalgia rheumatica (PMR) is a common inflammatory condition of unknown aetiology with a prevalence of 1 in 133 in the over 50s, and a female to male ratio of 2:1. Symptoms develop over a matter of weeks; typically bi...
Polymyalgia rheumatica (PMR) is a common inflammatory condition of unknown aetiology with a prevalence of 1 in 133 in the over 50s, and a female to male ratio of 2:1. Symptoms develop over a matter of weeks; typically bilateral shoulder or pelvic girdle pain and stiffness, that is worse in the mornings. Associated symptoms include low-grade fever, malaise, fatigue, low mood, poor appetite, and weight loss. There is no specific diagnostic test for PMR but the usual pattern is a commensurate rise in CRP and ESR. A small proportion of PMR patients will have normal inflammatory markers. PMR is associated with giant cell arteritis (GCA). Half of patients with GCA will have some PMR symptoms and up to one fifth of patients with PMR will have evidence of GCA. Other conditions that can mimic PMR include: rheumatic disease in the elderly e.g. rheumatoid arthritis; inflammatory muscle diseases; thyroid disease; malignancy; infection; bilateral shoulder capsulitis; osteoarthritis, Parkinsonism and depressive illness. At diagnosis and each follow-up visit it is imperative to consider the potential for associated GCA. The patient should be asked about headaches, jaw claudication and visual disturbance. If there is any suspicion of GCA, urgent discussion with the rheumatologist should take place that day.
Does testosterone therapy raise the risk of VTE?
Rees J
Practitioner · 2016 Dec · PMID 29020437
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Managing actinic keratosis in primary care.
Salmon N, Tidman MJ
Practitioner · 2016 Oct · PMID 29016090
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. Risk factors include: advanced age; male gender; cumulative...
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. Risk factors include: advanced age; male gender; cumulative sun exposure or phototherapy; Fitzpatrick skin phototypes I-II; long-term immuno-suppression and genetic syndromes e.g. xeroderma pigmentosum and albinism. Actinic keratoses are regarded by some authorities as premalignant lesions that may transform into invasive squamous cell carcinoma (SCC) and by others as in situ SCC that may progress to an invasive stage. The risk of malignant change appears low; up to 0.5% per lesion per year. Up to 20-30% of lesions may spontaneously regress but in the absence of any reliable prognostic clinical indicators regarding malignant potential active treatment is considered appropriate. Actinic keratosis lesions may present as discrete hyperkeratotic papules, cutaneous horns, or more subtle flat lesions on sun-exposed areas of skin. The single most helpful diagnostic sign is an irregularly roughened surface texture: a sandpaper-like feel almost always indicates actinic damage. 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 SCC. The principal indication for referral to secondary care is the possibility of cutaneous malignancy. However, widespread and severe actinic damage in patients who are immunosuppressed is also a reason for referral.
Early recognition vital in acute coronary syndrome.
Basu J, Sharma S
Practitioner · 2016 Oct · PMID 29016088
Acute coronary syndrome (ACS) includes both ST (STEMI) and non ST elevation (NSTEMI) MI, and unstable angina. The common pathological process underlying MI involves thrombus formation on top of a complex atheromatous pla...
Acute coronary syndrome (ACS) includes both ST (STEMI) and non ST elevation (NSTEMI) MI, and unstable angina. The common pathological process underlying MI involves thrombus formation on top of a complex atheromatous plaque, resulting in partial or complete occlusion of the coronary artery and myocyte necrosis. Unstable angina is defined as ischaemia at rest or on minimal exertion in the absence of myocyte necrosis. Patients with ACS typically present with chest pain; classically central chest pain that radiates to the left arm. Additional symptoms include dyspnoea, nausea, sweating and syncope. Patients can present atypically with gastric symptoms. These are often more common in patients with diabetes, women and the elderly. Clinical risk factors should also be considered when diagnosing ACS as this increases the likelihood of a positive diagnosis. Risk factors include: being older, male, a current or former smoker, known coronary artery disease (CAD), peripheral vascular disease, diabetes, hypercholesterolaemia, renal failure and a family history of CAD. A 12-lead ECG should be performed if possible within 10 minutes of presentation or ideally at first contact with the emergency services. Troponin should be measured on admission and at 12 hours. Ideally high sensitivity troponin should be measured as this has higher negative predictive values for MI and enables earlier detection of acute MI. A chest x-ray should also be carried out to assess for thoracic pathologies. An echocardiogram should be performed during admission in all patients with NSTEMI and STEMI.
Prompt diagnosis of AF lowers risk of complications.
Leo M, Betts T
Practitioner · 2016 Oct · PMID 29016085
Atrial fibrillation (AF) is the most common sustained heart rhythm disturbance. Estimates suggest an AF prevalence as high as 2% in adults with an exponential relationship with increasing age. AF is associated with a 1.5...
Atrial fibrillation (AF) is the most common sustained heart rhythm disturbance. Estimates suggest an AF prevalence as high as 2% in adults with an exponential relationship with increasing age. AF is associated with a 1.5-2 fold increased risk of death, and is responsible for 20-30% of all strokes. There are strong relationships with hypertension, heart failure, coronary artery disease (CAD), valvular heart disease, obesity, diabetes mellitus, COPD, obstructive sleep apnoea, chronic kidney disease and lifestyle factors such as increased alcohol intake, strenuous physical exercise and smoking. Assessment should include physical examination (blood pressure measurement, cardiovascular examination to look for valvular heart disease or heart failure and lung examination looking for signs of lung disease or pulmonary oedema), blood tests, including urea and electrolytes, liver function tests, full blood count, blood glucose and thyroid function tests. Signs of haemodynamic instability or severe symptoms (unstable angina, evolving TIA or stroke, heart failure or severe bradycardia) should be promptly identified and lead to urgent referral to specialist care. The CHA2DS2-VASc risk stratification score is recommended to assess stroke risk in patients with AF. Oral anticoagulation should be offered to those with a CHA2DS2-VASc score ≥ 2, and considered for men with a score of 1 and women with a score of 2. Risk of severe bleeding with warfarin should also be assessed using the HAS-BLED score.
Active monitoring vs treatment for localised prostate cancer.
Rees J
Practitioner · 2016 Oct · PMID 29016076
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Taken to task by my older patients.
Haslam D
Practitioner · 2016 Nov · PMID 28968054
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Improving the identification and monitoring of cirrhosis.
Keane MG, Hensher C, Pereira SP
Practitioner · 2016 Nov · PMID 28968053
Morbidity and mortality associated with cirrhosis are on the increase. In a recent UK cohort study the incidence of cirrhosis increased by 50.6% between 1998 and 2009. Although all causes of liver disease increased durin...
Morbidity and mortality associated with cirrhosis are on the increase. In a recent UK cohort study the incidence of cirrhosis increased by 50.6% between 1998 and 2009. Although all causes of liver disease increased during this period, this trend was primarily attributed to rising levels of alcohol misuse and obesity. Cirrhosis generally results from chronic liver damage over many years. It is characterised by fibrosis and nodularity of the parenchyma, which interferes with the synthetic, metabolic and excretory functions of the liver. Common causes include: alcohol misuse, hepatitis B (± delta) and hepatitis C and non-alcoholic fatty liver disease. Abdominal ultrasonography is a good first-line investigation in patients with suspected liver disease. The most commonly used serum biomarker is the enhanced liver fibrosis panel. Transient elastography is a specialist radiological test, which quantifies liver compliance. Compared with a standard biopsy, it will assess a much larger proportion of the liver and therefore sampling errors should be reduced. The measurements are painless and quick and serial measurements for monitoring treatment response e.g. in chronic viral hepatitis, are feasible and acceptable to patients. Patients with confirmed cirrhosis should be assessed for potential complications (ascites, encephalopathy, oesophageal varices or hepatocellular carcinoma). Reviewing cirrhotic patients regularly in primary care provides a valuable opportunity to ensure hepatocellular carcinoma and variceal surveillance is being undertaken and to give advice on losing weight or reducing alcohol intake.
Assessment and management of active and latent TB.
Shepherd JG, Chapman ALN
Practitioner · 2016 Nov · PMID 28968052
More than 25% of the world population has been infected with tuberculosis (TB), however only 10% of those infected will ever develop active disease. Clinically significant disease occurs through progression of primary in...
More than 25% of the world population has been infected with tuberculosis (TB), however only 10% of those infected will ever develop active disease. Clinically significant disease occurs through progression of primary infection or through later reactivation of latent TB infection (LTBI); this is most likely to occur in the first few years following infection, although late reactivation can occur several decades later, particularly in individuals who become immunosuppressed. Risk of TB acquisition is increased in people who have come to the UK from high incidence countries or who are born in the UK but come from high-risk ethnic minority groups. In 2015, 73% of those diagnosed with active TB were born outside the UK. Other risk groups include those who are homeless, in prison or who misuse drugs or alcohol. Once infected people who are immunosuppressed are at greater risk of progression to active disease. Infants below the age of 12 months can develop rapidly progressive and potentially fatal infection. Initial clinical assessment with chest radiography and the collection of three deep respiratory samples for smear microscopy and culture remain the standard of care. The management of active TB has not changed significantly over many years. The most significant changes in the 2016 NICE guidance relate to screening for LTBI in individuals who are contacts of a patient with active TB, or who are recent entrants to the UK from a high incidence country. NICE recommends that only contacts of patients with active pulmonary or laryngeal TB be screened.
GPs have key role in improving outcomes in acute asthma.
Grover HL, Higgins BG
Practitioner · 2016 Nov · PMID 28968051
Asthma deaths in the UK remain among the highest in Europe. The 2014 National Review of Asthma Deaths looked at detailed data over a 12-month period assessing 195 patients who died from asthma and highlighted the avoidab...
Asthma deaths in the UK remain among the highest in Europe. The 2014 National Review of Asthma Deaths looked at detailed data over a 12-month period assessing 195 patients who died from asthma and highlighted the avoidable factors in patient deaths. Although faults were found in secondary care, many of the problems related to poor management of patients in the community, both in terms of regular surveillance and assessment and treatment at the onset of attacks. Features which indicate a high risk of severe attacks include: previous admission to intensive care, particularly if requiring mechanical ventilation; previous admission with asthma especially in the past year or repeated emergency admissions; history of worsening asthma in January or February; use of three or more classes of asthma medication; heavy use of beta-2 agonists; anxiety traits; and marital stress. Peak expiratory flow improves the recognition of severity when compared with examination alone. Oxygen should be used to maintain oxygen saturation of 94-98% and it is recommended that GP surgeries have oxygen and an oximeter available. For anything other than life-threatening asthma, a standard metered dose inhaler administered with repeated actuations via a large volume spacer is as effective as a nebuliser. If a nebuliser is used it should ideally be driven with oxygen but nebulisers should not be withheld if oxygen is not available. Oral steroids are required for all patients experiencing attacks of moderate severity or worse as they improve symptoms and reduce mortality, hospital admissions and the need for beta-2 agonists.
Quantifying risk of embolism with different COCP formulations.
Barclay C
Practitioner · 2016 Nov · PMID 28968050
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Diabetes therapy does not raise risk of breast cancer.
Lockyer M
Practitioner · 2016 Nov · PMID 28968049
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Comparing compliance with new anticoagulants in AF patients.
Savill P
Practitioner · 2016 Nov · PMID 28968048
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Does the choice of forceps during IUD insertion affect pain scores?
Ma R
Practitioner · 2016 Nov · PMID 28968047
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Take-home naloxone provision cuts opioid overdose deaths.
Thompson J
Practitioner · 2016 Nov · PMID 28968042
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Set individualized targets for patients with type 2 diabetes.
Rajeev SP, Wilding J
Practitioner · 2016 Sep · PMID 29116730
Type 2 diabetes is a chronic, progressive, metabolic disorder caused by defects in insulin secretion and action resulting in hyperglycaemia. Fasting blood glucose, random blood glucose, the oral glucose tolerance test an...
Type 2 diabetes is a chronic, progressive, metabolic disorder caused by defects in insulin secretion and action resulting in hyperglycaemia. Fasting blood glucose, random blood glucose, the oral glucose tolerance test and glycated haemoglobin (HbA1c) tests are all used in diagnosis. In patients with impaired fasting glucose, impaired glucose tolerance or prediabetes there are minor variations in the risk of developing overt diabetes. The mainstay of management is lifestyle intervention i.e. diet and physical activity aiming for at least 5% weight loss for all these three states which can halve the risk of developing type 2 diabetes. Structured education is an integral part of diabetes care and this should be provided at diagnosis. Nutritional advice from a dietitian is essential. Regular physical activity totalling 30 minutes most days of the week improves muscle insulin sensitivity, lipid profile and blood pressure although a total of 60-75 minutes a day is required for reduction in body weight and better metabolic profiles. NICE guidelines acknowledge the need for individualised treatment targets. Lowering HbA1c is beneficial in reducing microvascular complications and may have macrovascular benefits in the long term. However, intensive glycaemic control in the elderly with more advanced disease may not have similar benefits and poses a risk due to hypoglycaemia.
Diagnosis and management of motor neurone disease.
Orrell RW
Practitioner · 2016 Sep · PMID 29116729
Motor neurone disease is a rapidly progressive and fatal neurodegenerative condition which causes progressive weakness, with normal sensation. It can occur at any age but is more frequent with increasing age. Key clinica...
Motor neurone disease is a rapidly progressive and fatal neurodegenerative condition which causes progressive weakness, with normal sensation. It can occur at any age but is more frequent with increasing age. Key clinical presentations include bulbar (slurred or difficult speech, problems swallowing, tongue fasciculation), limb (typically in one limb with weakness and muscle wasting), respiratory (breathlessness, chest muscle fasciculation) and cognitive features (behavioural change, emotional lability, features of frontotemporal dementia). Although survival is typically three to five years from symptom onset, there is significant individual variation. Rarely, survival may be 20 years or longer. Favourable features include a limb rather than a bulbar presentation, preserved weight and respiratory function, younger age of onset and longer time from fist symptom to diagnosis. The patient should be linked to a multidisciplinary team able to provide support from the start with a designated individual as the point of contact, with regular, coordinated assessments, as the patient's needs change and their condition progresses. Gastrostomy is an important supportive intervention which maximizes nutrition, and minimizes aspiration and chest infection. Adequate nutrition and hydration is key to maximizing health and survival. It is possible for a patient to control a computer and speech by eye. movement alone. An important consideration is voice banking where the patient may store their voice before there is difficulty with speech so that it can be used at a later stage if they need a communication aid. Impaired cough and retention of respiratory secretions is frequent in the later stages, and may be managed with physiotherapy. The patient should be referred for expert respiratory assessment if needed.
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