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The Practitioner

The Practitioner is a PubMed indexed journal, primarily aimed at GPs, with subscribers throughout the World. It is also used by doctors preparing for work in the UK. All articles in The Practitioner online include CPD fillable PDF 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

Prompt diagnosis of AF lowers risk of complications

24 Oct 2016Registered users

Estimates suggest an AF prevalence as high as 2% in adults with an exponential relationship with increasing age. Opportunistic screening for silent AF is recommended in at-risk groups. AF is associated with a 1.5-2 fold increased risk of death, and is responsible for 20-30% of all strokes. The CHA2DS2-VASc risk stratification score is recommended to assess stroke risk in patients with AF. Risk of severe bleeding with warfarin should also be assessed using the HAS-BLED score.

Early recognition vital in acute coronary syndrome

24 Oct 2016Registered users

Acute coronary syndrome (ACS) includes both ST (STEMI) and non ST elevation (NSTEMI) MI, and unstable angina. 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. However, patients can present atypically with gastric symptoms. These are often more common in patients with diabetes, women and the elderly. A 12-lead ECG should be performed if possible within 10 minutes of presentation or ideally at first contact with the emergency services.

 

Special reports

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.

 

Clinical reviews of research - by GPs with interest

AF linked to raised risk of a wide range of conditions

24 Oct 2016Registered users

Atrial fibrillation (AF) is associated with an increased risk of death, heart failure, chronic kidney disease and major cardiovascular events as well as stroke, a large meta-analysis has found.

Does alcohol consumption reduce fertility?

24 Oct 2016Registered users

Drinking in moderation does not appear to have an adverse effect on a woman’s ability to conceive, a prospective cohort study from Denmark has found.

Diabetes therapy and bladder cancer risk

24 Oct 2016Registered users

A UK population-based cohort study concludes that pioglitazone is associated with an increased risk of bladder cancer in patients with type 2 diabetes.

A diagnosis of cancer can affect mental health

24 Oct 2016Registered users

Cancer patients have an increased risk of developing common mental health disorders from 10 months prior to their cancer diagnosis, with a peak incidence during the first week after diagnosis,a Swedish study has found.

 

HASLAM's view

A memorable lesson in patient-focused consultation

24 Oct 2016Registered users

When I eventually turned back to the patient, I discovered that he was sitting there silently crying, tears running down his face. This, of course, was clue number two. It was not so much a clue, rather a slap in the face for my insensitivity. I apologised. I felt embarrassed and annoyed with myself. I immediately turned the computer off.

 

Pain management

Tailor treatment to the patient with neuropathic pain

23 Sep 2016

Neuropathic pain is defined as pain that is caused by a lesion or disease of the somatosensory nervous system and is estimated to affect 6-8% of the general population. A low threshold of suspicion in conditions associated with neuropathic pain can aid diagnosis. Typical neuropathic descriptors include burning, shooting, electric shock pain with numbness, pins and needles or itching.

Rapid diagnosis vital in thunderclap headache

25 Apr 2016Paid-up subscribers

Thunderclap headache is a severe and acute headache that reaches maximum intensity in under one minute and lasts for more than five minutes. Thunderclap headaches may be associated with symptoms such as photophobia, nausea, vomiting, neck pain, focal neurological symptoms or loss of consciousness. Subarachnoid haemorrhage (SAH) accounts for 10-25% of all thunderclap headaches and, despite advances in medical technology, has a 90-day mortality of 30%. Up to a quarter of cases of SAH are misdiagnosed, often through failure to follow guidance.

 

Controlling joint pain in older people

25 Jan 2016Paid-up subscribers

The prevalence of chronic pain in older people in the community ranges from 25 to 76% and for those in residential care, it is even higher at 83 to 93%. The most common sites affected are the back, hip, or knee, and other joints. There is increased reporting of pain in women (79%) compared with men (53%). Common conditions include osteoarthritis and, to a lesser extent, the inflammatory arthropathies such as rheumatoid arthritis. The differential diagnosis includes non-articular pain such as vascular limb pain and nocturnal cramp, some neuropathic pain conditions (such as compressive neuropathies and postherpetic neuralgia), soft tissue disorders such as fibromyalgia and myofascial pain syndromes. 

 

Women's health

Managing debilitating menopausal symptoms

21 Mar 2016Registered users

Severity and duration of menopausal symptoms varies markedly. Eight out of ten women experience symptoms and on average these last four years, with one in ten women experiencing symptoms for up to 12 years. Menopausal symptoms can begin years before menstruation ceases. A recent study found that women whose vasomotor symptoms started before the menopause suffered longest, median 11.8 years. Women whose hot flushes and night sweats started after the menopause had symptoms for a median of 3.4 years.

GPs have key role in early diagnosis of endometriosis

23 Mar 2015Registered users

Risk factors for endometriosis include early menarche, late menopause, delayed childbearing, vaginal outflow obstruction and a first-degree relative affected. Women commonly present to their GP with pelvic pain, painful intercourse or subfertility. Referral should be considered if pain is not controlled with simple analgesia or the diagnosis is suspected in a woman who is actively trying to conceive. Early referral should be considered in women with abnormal examination findings, or an abnormal ultrasound result.

 

Editorials

Active monitoring vs treatment for localised prostate cancer

24 Oct 2016

No significant difference in prostate cancer mortality was seen in men with localised prostate cancer who underwent active monitoring compared with surgery or radiotherapy at ten years’ follow-up in ProtecT, a large UK trial. However, both surgery and radiotherapy were associated with lower rates of metastasis and disease progression. ProtecT seems to support the use of active monitoring/surveillance in low-risk patients, but this does not mean that it is a sensible option for all men newly diagnosed with prostate cancer. Most men in ProtecT had low Gleason grade, low-risk disease and the findings must not be used to push men with more aggressive disease away from active treatment.

 

Diabetes

Set individualised targets for patients with type 2 diabetes

23 Sep 2016

In type 2 diabetes 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 weight reduction 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.

Improving the detection and management of type 1 diabetes

25 Jan 2016Registered users

Type 1 diabetes affects around 370,000 adults in the UK, about 10% of all those diagnosed with diabetes. In type 1 diabetes there is a lack of beta cell insulin secretion as a result of autoimmune destruction of the beta cells. However, patients are not affected by insulin resistance, and so do not routinely experience the features of metabolic syndrome that occur in type 2 diabetes. It is therefore important to classify the type of diabetes correctly and to recognise that type 1 diabetes is a condition with its own management requirements. Structured education is the cornerstone of care providing tools to allow effective self-management.

Improving outcomes in diabetes in pregnancy

21 May 2015Registered users

One in 250 pregnancies in the UK involves diabetes. The majority of cases (87.5%) are gestational diabetes, 7.5% are type 1 and 5% are type 2 diabetes. Diabetes in pregnancy is associated with a five fold increase in risk of stillbirth and a two-fold increased risk of congenital defects compared with the general maternity population. Women with gestational diabetes have a significant lifetime risk of developing type 2 diabetes, hence diabetes screening must be undertaken on an annual basis in primary care.

Managing patients with type 2 diabetes and obesity

22 Jan 2015Registered users

Diabetes risk increases exponentially with increasing BMI particularly if fat accumulates centrally and/or in the skeletal muscle, liver and other organs such as the pancreas. Those with diabetes and co-existing obesity, particularly if it is severe, are also at risk of other obesity-related conditions, such as cardiovascular disease, obstructive sleep apnoea, joint pain, many cancers and depression. Supporting patients to lose weight should be considered a key goal of diabetes care for all overweight and obese patients with type 2 diabetes.

 

PHOTOGUIDE

Papulosquamous conditions

23 Sep 2016Registered users

• Pityriasis rosea • Discoid lupus erythematosus • Lichen planus • Seborrhoeic dermatitis • Tinea corporis • Plaque psoriasis

Sun damage

23 Jun 2016Registered users

 • Squamous cell carcinoma • Actinic keratosis horn • Bowen’s disease • Solar elastosis • Rosacea • Discoid lupus

 

CPD exercises associated with each issue

CPD exercise October 2016

24 Oct 2016Paid-up subscribers

All articles in The Practitioner online now 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: • Prompt diagnosis of AF lowers risk of complications • Early recognition vital in acute coronary syndrome • Managing actinic keratosis in primary care