The Practitioner is a Pub Med indexed general medical review monthy journal with subscribers throughout the World. CPD: The CPD exercise is known to be used widely in the UK (75% of readers sometimes or always complete the exercise) and 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
Symposium
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Diagnosing and managing vascular dementia
24 Jan 2012
Vascular dementia (VaD) is common. Pure vascular disease may account for 5–20% of all cases of dementia, while mixed dementia, Alzheimer's disease (AD) with VaD, occurs at least as frequently. It is unusually heterogeneous and frequently overlapping and comorbid with other conditions such as stroke, other cardiovascular and cerebrovascular diseases and their risk factors, as well as AD. There is no specific treatment or cure for VaD, but its proximity to other conditions may make it amenable to interventions at various stages of the disease. Most recent research suggests that VaD and AD occupy ends of the same spectrum and share common risk factors. As VaD is closely related to cardiovascular disease, modifying cardiovascular risk factors may assist in its prevention. Cardiovascular risk factors such as hypertension, dyslipidaemia, obesity, smoking and diabetes are closely associated with cognitive impairment, AD, as well as VaD. While hypertension in midlife increases the risk of all-cause dementia including AD, a reduction in blood pressure may occur with the onset of AD. Regular screening of high-risk individuals could help to detect dementia early on and enable appropriate preventive intervention. This could involve pharmacological as well as behavioural modulation of risk factors. Medication for hypertension, diabetes and hypercholesterolaemia is recommended, as treatment reduces the risk of developing cognitive impairment and dementia. Behavioural treatments include enhancing and encouraging cognitive and physical activity, social engagement, smoking cessation and healthy diet, including alcohol reduction. Although smoking and excessive alcohol consumption are so far not directly linked to VaD, they are risk factors for cardiovascular disease and stroke and should be treated as indirect risk factors. It should not be forgotten that depressive illness or symptoms in old people can affect their cognitive function and worsen existing cognitive impairment.
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Musculoskeletal medicine: Early diagnosis crucial in ankylosing spondylitis
16 Dec 2011
Back pain is common with up to 9% of the population consulting their GP with this problem each year. As the vast majority of these patients have non-specific back pain, it is often difficult to identify those with inflammatory disease such as ankylosing spondylitis (AS). It is critical to make this distinction as AS, if untreated, may cause significant morbidity with a substantial socio-economic impact both on the individual and society. Early diagnosis is particularly important as newer therapies are able to contain this condition and even induce remission in some cases. AS affects about 0.2-0.5% of the population. It is at least twice as common in men than women and most often manifests in the third to fifth decades. It is estimated that up to 5% of patients with chronic lower back pain in primary care have inflammatory disease. Diagnosis is usually delayed at least partly through lack of awareness of this condition.
Special report and casebook
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Diagnosing autism spectrum disorders in primary care
22 Nov 2011
Autism, like most psychiatric disorders, covers a spectrum of severity from severely disabling classic autism to milder forms of Asperger’s syndrome which border on normality. The term autism spectrum disorder (ASD) includes autism, atypical autism and Asperger’s syndrome. Some parents consult their GP worried that their child might have autism. Others may attend with a range of concerns that might point to the condition such as problems with hearing, vision, hypersensitivity to sensory stimuli, behaviour management, language impairment or repetitive behaviour. Autism conditions often co-exist with neurological disorders (particularly those including epilepsy), and more than 300 syndromes which include autism have been described.The new NICE guidelines, launched in September 2011, cover children, from birth up to 19 years, on the autism spectrum and build on the guidance published by SIGN in 2007.ASD was once believed to be relatively rare but is now thought to occur in about 1% of children. There is certainly increasing demand for diagnostic services for children and young people. Whether the apparent increasing prevalence signifies an epidemic or an epidemic of discovery is debatable.
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Be vigilant for common mental health disorders
19 Oct 2011
Common mental health disorders affect as many as one in six people in the community. The 2007 ONS household survey of adult psychiatric morbidity in England found that 16.2% of 16-64 year olds were suffering from an anxiety or depressive disorder. Of those 4.4% were diagnosed with generalised anxiety disorder (GAD); 3.0% with post-traumatic stress disorder (PTSD); 2.3% with major depression; 1.4% with phobias; 1.1% obsessive compulsive disorder (OCD); and 1.1% with panic disorder. The conditions are not mutually exclusive and the most common problem was mixed anxiety and depression, found in 9% of patients. The diagnoses were established through diagnostic psychiatric interviews with subjects screening positive in the survey.These disorders are even more common in primary care. The New Zealand Magpie Study found that 20.7% of people presenting to primary care had suffered a common mental health disorder over a 12-month period, compared with 14.8% in the community.
Clinical Reviews
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Music therapy beneficial as an adjunct for depression
16 Dec 2011
Individual music therapy improves outcomes in depression when combined with standard therapy, a randomised controlled trial from Finland has found. A total of 79 participants (62 women), aged 18 to 50, with an ICD-10 diagnosis of depression were recruited from psychiatric health centres and polyclinics. Thirty three were allocated to the intervention group and 46 received standard care only. The intervention consisted of 20 twice-weekly sessions, each session lasting for one hour. Both the therapist and patient were provided with a keyboard, percussion instrument and acoustic drum. A therapeutic musical relationship was developed by improvising music together.
Is music an effective training aid for CPR?
16 Dec 2011
Listening to repeated choruses of Disco Science can improve the rate of chest compressions in subjects carrying out cardiopulmonary resuscitation (CPR) but does not help to achieve the correct depth of compressions, a study has found. Dr Peter Savill reviewed the paper: 'Significantly more delegates maintained compressions within the optimal range of 100 to 120 compressions a minute when listening to Disco Science than when listening to Achy Breaky Heart (82% vs 64%, p=0.07). Achy Breaky was no better than no music (64% vs 65%). However, compressions were still too shallow irrespective of the background music; 39% at the correct depth with Disco Science, 43% with Achy Breaky and 42% with no music. Furthermore, incorrect hand positioning was rife and seen in up to two thirds of delegates. The authors were therefore unconvinced that music provides any benefit in improving the quality of CPR compared with a metronome or audible feedback. Time to abandon iPod augmented CPR then!'
PHOTOGUIDE
Editorial
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Time to tackle obesity
16 Dec 2011
Obesity is defined as a body mass index (BMI) ≥30 kg/m2and it is estimated that almost a quarter of the population of England are obese. Primary care physicians are familiar with the subsequent problems that can arise such as diabetes, cardiovascular disease and osteoarthritis to list but a few. At present the Quality and Outcomes Framework places little emphasis on obesity management and there are few options available in traditional models of primary care. Patients will often self select for various commercial weight management programmes and in some areas these are available on the NHS. There is certainly evidence to support the notion of centrally funded commercial weight loss programmes. Another option is for primary care teams to develop in-house obesity management programmes. Dr Peter Savill looks at recent evidence on the effectiveness of such options for treatment.
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Strokes have declined but atrial fibrillation is still undertreated
22 Nov 2011
Stroke is a major cause of morbidity and mortality. Primary care has a central role to play in prevention with the identification and management of hypertension, obesity, high cholesterol, atrial fibrillation (AF) and diabetes. A recent study has found that both the incidence of stroke and stroke deaths declined significantly over the past decade in the UK. This was accompanied by a notable increase in GP prescribing for primary and secondary prevention which is likely to have been a major contributing factor, the study authors conclude. However, the study also found underuse of anticoagulants in patients with AF at high risk of stroke, particularly in women.
100 Years ago
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100 years ago: The GP and the Medical Society
16 Dec 2011
By J. Mitchell Bruce, M.A., LL.D. (Hon.), MD, F.R.C.P. Presidential address delivered in 1911 before the Medical Society of London: 'Is the object of the Medical Society entirely fulfilled in the routine work of our meetings? I find that, whilst those who are in general practice constitute one-third of our number, only one communication in 15 comes from them – that they have read but four papers before the Society during the past 10 years...Let me call to mind some of the great things that have been accomplished by the family practitioner. I have but to mention the name of Edward Jenner, Fellow of our Society. Was not Koch a general practitioner; and Duchenne of Boulogne? And was it not the work that Manson did on filarial disease, when a practitioner in China, that led him to the induction of the relation of malaria to blood-sucking insects? Something short of the results of the achievements of these men in general practice would satisfy me.'
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100 years ago:Tuberculin in pulmonary tuberculosis
22 Nov 2011
100 years ago: 'Tuberculin plays an important part in the treatment of pulmonary tuberculosis in certain cases, and that its efficacy is greatly increased when it is diluted with a 1 per cent. solution of carbolic acid. However, tuberculin cannot take the place of sanatoria. Too much value is placed on tuberculin by tuberculin enthusiasts. It has an important place in the treatment of pulmonary tuberculosis, but must on no account be allowed to usurp sanatorium treatment. Its use is restricted to certain cases.'
CPD exercises associated with each issue
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Practitioner CPD exercise - December 2011
16 Dec 2011
The Practitioner exercise this month includes questions on gout, ankylosing spondylitis and obesity from the relevant articles in the December issue.
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Practitioner CPD exercise - November 2011
22 Nov 2011
The CPD exercise in the November issue includes questions on lung cancer, TB, and autism spectrum disorders.
HASLAM's view
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It’s a fine line between health and illness
16 Dec 2011
'The more I study depression the less I think I understand it. The fact that someone has massive social problems doesn’t automatically mean that he or she can’t be suffering from a biochemical depression and vice versa. However, discerning the point at which medication is appropriate can be ludicrously difficult, and full of unintended consequences. For instance, if a GP offers treatment to someone who is distressed by their living conditions and the intransigence of an unsympathetic council housing department, and as a result of medication he or she feels better, then will those living conditions ever improve? But how can we be certain that the cause of the depression really is the living conditions? Could it not be that the cause is infinitely more complex? When do we become agents of the status quo?...' Professor David Haslam, President of the BMA, Past President RCGP, National Clinical Adviser, to the Care Quality Commission
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