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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.

 

Case reports

Ulnar nerve injury on removal of a contraceptive implant

15 Dec 2016Registered users

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.

 

Symposium

Diagnosis and management of polymyalgia rheumatica

16 Dec 2016Paid-up subscribers

Polymyalgia rheumatica (PMR) is a common inflammatory condition of unknown aetiology. 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. At diagnosis and each follow-up visit it is imperative to consider the potential for associated giant cell arteritis (GCA). If there is any suspicion of GCA, urgent discussion with the rheumatologist should take place that day.

Improving joint pain and function in osteoarthritis

16 Dec 2016Paid-up subscribers

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. 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.

Assessment and management of active and latent TB

24 Nov 2016Paid-up subscribers

Risk of acquisition of TB 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. Other risk groups in the UK 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. One group at particularly high risk are infants below the age of 12 months who can develop rapidly progressive and potentially fatal infection. It is important for TB teams to be aware of infants who may have been exposed to an infectious case and to refer the child to paediatric services as a matter of urgency.

GPs have key role in improving outcomes in acute asthma

24 Nov 2016Paid-up subscribers

There are 5.4 million people with asthma in the UK.1 Attendance at both GP surgeries and emergency departments is high and in 2011-12 there were more than 65,000 hospital admissions, a higher admission rate than most comparable European countries. Asthma deaths in the UK remain among the highest in Europe. The 2014 National Review of Asthma Deaths (NRAD) 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 of assessment and treatment at the onset of attacks.

 

Clinical reviews of research - by GPs with interest

Use of infant simulators does not reduce teenage pregnancies

15 Dec 2016Paid-up subscribers

Providing teenage girls with an infant simulator doll for a few days appeared to increase rather than decrease the risk of pregnancy, in a study from Western Australia.

Will a cup of tea a day keep the cardiologist away?

15 Dec 2016Paid-up subscribers

Moderate tea consumption was associated with a slower progression of coronary artery calcium and lower incidence of major cardiovascular events, a study published in the American Journal of Medicine has found. Regular coffee consumption had neither protective nor adverse effects.

Drinking levels in young women are approaching those of men

15 Dec 2016Paid-up subscribers

The traditional gender difference in alcohol misuse and alcohol-related harm, where men have been at much higher risk than women is changing, a recent study has confirmed.

Whole body hyperthermia for depression

15 Dec 2016Paid-up subscribers

Whole body hyperthermia (WBH) shows promise as an effective treatment for depression, a randomised double-blind,sham-controlled trial, published in JAMA Psychiatry, has concluded.

 

HASLAM's view

Why is it easier to give advice than to take it?

15 Dec 2016Paid-up subscribers

 ‘I suddenly realised that it was my pain, not yours. It was my job to sort it out, not the physio, or you doctor or anyone else. And so, for the first time, I actually started to do the exercises, and follow the advice you’ve all given me.’

 

Special reports

Improving the identification and monitoring of cirrhosis

23 Nov 2016Paid-up subscribers

By 2012, cirrhotic patients admitted to hospital were six times more likely to die compared with patients admitted for any other reason. Nearly half of liver disease admissions were for alcohol-related liver disease and were associated with a 12.3% mortality. Cirrhosis is more common in urban and socially deprived areas. The NHS Atlas of Variation in Healthcare for People with Liver Disease found that the highest rates of hospital admission for end-stage liver disease due to chronic hepatitis C virus were in central London and the North West of England. Admissions for alcohol-related liver disease were also most common in the North West.

Managing actinic keratosis in primary care

24 Oct 2016Paid-up subscribers

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.

 

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. 

 

Editorials

Does testosterone therapy raise the risk of VTE?

16 Dec 2016Registered users

The evidence remains inconclusive as to whether testosterone increases the risk of VTE significantly. However, it would appear sensible, if initiating testosterone replacement, particularly in those with a past history of VTE or other significant risk factors, to mention the concern over this, and advise early reporting of any potential symptoms of VTE.

Take-home naloxone provision cuts opioid overdose deaths

23 Nov 2016Paid-up subscribers

Take-home naloxone programmes significantly reduce fatal outcomes of opioid overdose, a systematic review has found. In these programmes illicit opioid injectors, their peers, friends, relatives and carers are provided with overdose management training together with naloxone kits for emergency injection if someone they are with is suspected of having symptoms of opioid overdose, with a view to preventing death.

 

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 2015Paid-up subscribers

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 2015Paid-up subscribers

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 - December 2016

15 Dec 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: • Ulnar nerve injury on removal of a contraceptive implant • Diagnosis and management of polymyalgia rheumatica • Improving joint pain and function in osteoarthritis

CPD exercise - November 2016

24 Nov 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: • GPs have key role in improving outcomes in acute asthma • Assessment and management of active and latent TB • Improving the identification and monitoring of cirrhosis