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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

Preventing stroke and assessing risk in women

22 Mar 2017Registered users

Ischaemic stroke is rare in premenopausal women but risk increases with advancing age and doubles in the ten years following the menopause. Up to the age of 75 years men have a 25% higher risk of suffering a stroke compared with women. However, the increased life expectancy of women ultimately results in a higher overall incidence. Twice as many women die from stroke compared with breast cancer. Women with cerebrovascular disease are more likely to present with atypical symptoms than men. Atrial fibrillation and hypertension, although less common than in men, are more potent risk factors for stroke in women.

Tailor management to the patient with fibroids

22 Mar 2017Registered users

Fibroids are benign, hormone-dependent tumours of uterine smooth muscle and connective tissue. They are commonly asymptomatic, but can cause symptoms such as heavy menstrual bleeding and pelvic pressure symptoms. Between 20 to 30% of women with heavy menstrual bleeding have fibroids. Fibroids are most prevalent in women aged 30-50 years and there may be a genetic predisposition. They are more common in black women than white women. Other risk factors include obesity and nulliparity. Asymptomatic women should only be referred if their uterus is palpable abdominally, if fibroids distort the uterine cavity or the uterus is larger than 12 cm in length.

Diagnosis and management of nephrotic syndrome

22 Feb 2017Paid-up subscribers

Nephrotic syndrome is uncommon in general practice. A GP may only see two or three adult cases in their career. Nephrotic syndrome develops following pathological injury to renal glomeruli. This may be a primary problem, with a disease specific to the kidneys, or secondary to a systemic disorder such as diabetes mellitus. The most common cause in children is minimal change glomerulonephritis. In white adults, nephrotic syndrome is most frequently due to membranous nephropathy whereas in populations of African ancestry the most common cause of nephrotic syndrome is focal segmental glomerulosclerosis (FSGS). Diabetic nephropathy is the most common multisystem disease that can cause nephrotic syndrome. 

Pyelonephritis can lead to life-threatening complications

22 Feb 2017Paid-up subscribers

As distinct from cystitis and lower urinary tract infection (UTI), which are much more common, pyelonephritis involves the upper tract with potentially more serious sequelae. It is most commonly caused by bacterial infections, typically ascending from the lower urinary tract; haematological seeding from bacteraemia is less common.

 

Special reports

Improving pain control in diabetic neuropathy

22 Mar 2017Registered users

Diabetic neuropathy is thought to affect 1.9% of the world’s population and 50% of patients with a diagnosis of diabetes mellitus which would equate to 2.25 million people in the UK. The term diabetic neuropathy includes multiple distinct clinical entities that have been classified under the broad headings of focal and multifocal neuropathies and symmetrical neuropathies. Peripheral diabetic neuropathy, a chronic distal symmetrical predominantly sensory neuropathy, is the most common form of diabetic neuropathy. The common presentation is of painful symptoms originating in the feet, that then spread to the knees before involving the distal portion of the upper limbs in a ‘glove and stocking’ distribution.

Be vigilant for skin manifestations of inherited cancer syndromes

23 Jan 2017Registered users

More than 200 hereditary cancer susceptibility syndromes have been described, and it is thought that they account for 5-10% of all cancers. Many have dermatological manifestations (usually lesions, occasionally rashes) which frequently precede other systemic pathology. Dermatological signs are usually non-specific and often trivial in appearance, making their significance easy to overlook and a clinical diagnosis challenging.

 

Clinical reviews of research - by GPs with interest

Early catheter ablation improves outcomes in paroxysmal AF

22 Mar 2017Registered users

Patients with paroxysmal atrial fibrillation (AF) treated with catheter ablation first line showed significantly better improvement than those treated initially with drug therapy in a multicentre, randomised, unblinded trial. The Medical ANtiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation (MANTRA-PAF) trial compared radiofrequency catheter ablation with antiarrhythmic drug therapy as first-line treatment for paroxysmal AF.

GP vs clinic care for people living with HIV

22 Mar 2017Registered users

Around 60% of people living with HIV would choose GP care in preference to an HIV clinic, a UK study has found.

E-cigarette use linked to successful quit attempts

22 Mar 2017Paid-up subscribers

The rise in the use of e-cigarettes in England has been associated with an improvement in the success of quit attempts, a study in the BMJ has found.

Risk factors for antepartum stillbirth

22 Mar 2017Paid-up subscribers

Antepartum stillbirth is a complex syndrome associated with a range of risk factors, a prospective observational study has concluded.

 

Case reports

Artefact mimicking torsades: treat the patient not the ECG

22 Feb 2017Paid-up subscribers

There has been a marked increase in the availability and use of ECG machines in general practice. In 2008, Day and colleagues reported that 85% of GPs who responded to their survey had an ECG machine and that 91% of them used it at least once a week.  We report a case in which artefact was misinterpreted as torsades de pointes, often referred to simply as torsades. Our patient did not suffer any harm and did not have any unnecessary investigations, yet inappropriate treatment was administered making the potential for harm a real possibility. We describe the ECG features which differentiate artefact from torsades and review common sources of ECG artefact, in both hospital and general practice.

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.

 

HASLAM's view

What do GPs really do?

22 Mar 2017Registered users

I don’t really have any idea what people in different professions actually do all day. Do you? What do actuaries, astronomers or ethicists do when they arrive at work? In the same way, I’m pretty certain that not many people really understand what GPs do either. Pundits love to write about what GPs do, and what might be done differently or better, but I often wonder whether they really do understand the role and the challenge.

 

Editorials

Depression in adults linked to maltreatment in childhood

22 Mar 2017Registered users

Almost one in two depressed adult patients report maltreatment in childhood and are at increased risk of early onset, chronic or treatment-resistant depression, a meta-analysis has found. Maltreated individuals were between 2.45 times (childhood physical neglect) and 3.73 times (childhood emotional abuse) more likely than those who had not been maltreated to become depressed as adults. Childhood emotional abuse and neglect were most strongly associated with both risk of depression and depression severity.

MP-MRI could improve the diagnosis of prostate cancer

22 Feb 2017Paid-up subscribers

Multi-parametric magnetic resonance imaging (MP-MRI) could play an important role in triaging men with a raised PSA for prostate biopsy and improve the detection of clinically significant prostate cancer, findings from a UK study suggest.

 

CPD exercises associated with each issue

CPD exercise - March 2017

22 Mar 2017Paid-up subscribers

All articles in The Practitioner online 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: • Preventing stroke and assessing risk in women • Tailor management to the patient with fibroids
• Improving pain control in diabetic neuropathy

CPD exercise - February 2017

22 Feb 2017Paid-up subscribers

All articles in The Practitioner online 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:• Diagnosis and management of nephrotic syndrome • Pyelonephritis can lead to life-threatening complications • Artefact mimicking torsades: treat the patient not the ECG

 

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

Conditions affecting the hair and scalp

25 Apr 2016Registered users

• Dermatitis artefacta • Alopecia mucinosa • Lichen planopilaris • Discoid lupus erythematosus • Sebaceous naevus • Basal cell carcinoma

Fungal infections

21 Mar 2016Registered users

• Lingua villosa nigra • Onychomycosis • Tinea corporis • Tinea pedis • Id reaction • Tinea incognito