= Paid-up subscribersThe Practitioner is a PubMed indexed general medical review monthy journal with subscribers throughout the world. CPD: The CPD exercise is widely used in the UK (75% of GP readers sometimes or always complete the exercise) and the Middle East, and may be used by doctors in many other countries. The Practitioner and this website are also used by doctors preparing themselves to work in the UK.
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The Practitioner
Editorial
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Continuing donepezil produces cognitive benefits in Alzheimer’s
25 Apr 2012
Patients with moderately severe or severe Alzheimer’s disease benefit from continued treatment with donepezil, a year long UK study has found. Dr Phillip Bland, GP with an interest in mental health, Dalton-in-Furness, comments: 'The present study suggests that community residents with an MMSE score between 5 and 13 may derive a modest but potentially important benefit from continued treatment.'
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MI often presents without chest pain in women
21 Mar 2012
Women are often older than men at hospitalisation for myocardial infarction and present less frequently with chest pain. It is generally accepted that patients without chest pain tend to present later and are treated less aggressively than those presenting with more typical symptoms, and have almost twice the short-term mortality rate. Clinicians should not be dissuaded from urgent referral in high-risk patients by a rather atypical presentation and the lack of classical cardiac sounding chest pain.
CPD exercises associated with each issue
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The Practitioner CPD exercise April 2012
25 Apr 2012
This month's CPD exercise is on the following topics, based on articles in the April issue: BPH and prostate cancer; varicocoele; atopic eczema; and Alzheimer's disease. Registered users can download the new CPD study pack into their personal development plan folder.
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The Practitioner CPD exercise March 2012
21 Mar 2012
The Practitioner exercise this month includes questions on postmenopausal bleeding, caesarean section, anaphylaxis, myocardial infarction in women, and the use of SSRIs in pregnancy from articles in the March issue. Registered users can download the new CPD study pack into their personal development plan folder.
Symposium
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Is there a link between BPH and prostate cancer?
25 Apr 2012
GPs are playing an increasing role in managing both prostate cancer and benign prostatic hyperplasia (BPH). More than 70% of men over 70 years are affected by BPH, and prostate cancer is the most common cancer in men in the UK. GPs play an important part in the initial management of men presenting with lower urinary tract symptoms and in addressing concerns regarding prostate cancer and the significance of the patient’s symptoms. While there is no proven causal link between prostate cancer and BPH, associations have been found. BPH may increase the chance of an incidental prostate cancer being diagnosed through PSA testing and other investigations.
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When should patients with varicocoele be referred?
24 Apr 2012
Varicocoele is present in 15% of men. Patients suspected of having underlying malignant pathology or with significant discomfort from a large varicocoele should be referred for specialist review. The data regarding the relationship between the condition and infertility is inconclusive. NICE does not recommend surgical treatment of varicocoele for infertility. Patients or couples with infertility should be referred to a urologist with a specialist interest in fertility and an expert in assisted reproduction techniques, ideally to be seen in a joint clinic.
Special reports
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Improving the management of atopic eczema in primary care
25 Apr 2012
Although generally considered a childhood ailment, 38% of patients with atopic eczema in the UK are adults. The condition often has a significant detrimental effect on the quality of life of affected individuals and their families. The majority of care for atopic eczema is undertaken by the primary healthcare team. However, despite national evidence-based guidelines in the UK, standards of care in the community setting can vary, and there is still a tendency to undertreat and not follow up and monitor some patients adequately.
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Following up patients after treatment for anaphylaxis
21 Mar 2012
NICE has recently published guidelines on the care and follow-up of patients who have received emergency treatment for anaphylaxis. Once patients have been assessed in a specialist clinic, and provided with a tailored management plan, regular review will be necessary in primary care. Important aspects include ensuring that: adrenaline devices are in date; injection technique refresher sessions are available; background asthma is well controlled; any dietary restrictions have not led to an unhealthy diet (e.g. lack of adequate calcium source in patients avoiding dairy products).
HASLAM's view
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When does a phobia become an illness?
25 Apr 2012
'My wife hates spiders. I learnt long ago that a shriek from another room didn’t mean that a maniac with an axe had broken in, but that a half-inch spider had just careered across the carpet. An ability to tackle spiders has given me a touch of hero status in her eyes, as if I had seen off a gang of feral hooligans single-handed. There is no logic to phobias....I bet there’s something illogical that petrifies you...' writes our regular columnist Professor David Haslam.
PHOTOGUIDE
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Pigmented lesions
25 Apr 2012
This month's photoguide includes: blue naevus; giant comedone; seborrhoeic keratosis; congenital naevus; and dermatosis papulosa nigra.
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Scaley skin conditions
21 Mar 2012
This month's photoguide includes: seborrhoeic dematitis; exfoliative keratolysis; Darier’s disease; ichthyosis; idiopathic pityriasis amiantacea; and lichen planus.
100 Years ago
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Treatment of rheumatic disorders
30 Apr 2012
Selected notes from readers of The Practitioner in 1912 on rheumatic disorders: Treatment by bee stings, The country doctor and acute rheumatism, and Dr Percy Wilde’s Method
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A hundred years ago: Radium therapy in rheumatism
21 Mar 2012
'There is no doubt that in severe cases, and especially in acute rheumatism, the constant inhalation of strong radium emanation with oxygen to saturation of the system is of the greatest value; and no apparatus has given such excellent results as that which is shown here – the joint invention of Pro. Paul Zazarus and Dr. Saubermann. This apparatus is most useful when it is desired to highly charge the blood with radium emanation in order that it may exert its bactericidal power.'
Clinical Reviews
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Weigh up risks and benefits of smoking cessation treatments
26 Apr 2012
A comparative study using data from the US Food and Drug Administration (FDA) has found that the risk of depression and suicidal/self-harm behaviour is substantially greater with varenicline than with other smoking cessation treatments t(although the absolute risk of harm is low). Dr Phillip Bland, GP with an interest in mental health, Dalton-in-Furness assesses the import of this paper for UK primary care: I think it is reasonable to continue to offer varenicline as a first-line treatment, provided; we counsel patients to stop their treatment and seek immediate advice if they develop agitation, depression or suicidal thoughts; we closely monitor those with a previous history of psychiatric illness; we do not prescribe to high risk patients e.g. those with a previous history of attempted suicide; we liaise closely with smoking cessation services. I would advocate a shared-care protocol clarifying mutual responsibilities and the importance of passing on relevant information.'
Difference in BP readings between arms can predict outcomes in hypertension
25 Apr 2012
An inter-arm difference in systolic BP can predict cardiovascular morbidity and all-cause mortality after 10 years in patients with hypertension, a UK study in the BMJ has found. This cohort study was carried out in a rural general practice setting in Devon. It analysed 230 patients receiving treatment for hypertension; 47 of whom had cardiovascular disease at recruitment. The authors conclude that differences in systolic BP between arms can predict an increased risk of cardiovascular events and all-cause mortality over 10 years in patients with hypertension. They suggest that this could be used as another indicator of increased cardiovascular risk and furthermore that BP measurement on both arms should be performed as a matter of routine in primary care. ‘Assessment of BP in both arms is recommended by guidelines and should become a core component of initial BP measurement in primary care,’ the authors state.
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