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The Practitioner

The Practitioner contributes to the formal clinical literature and is 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

Tackling medication overuse headache in primary care

24 Sep 2018Registered users

Medication overuse headache (MOH) occurs as a complication of the management of primary headache disorders, mainly migraine and tension type headache. MOH does not occur in cluster headache unless there is associated migraine. MOH is defined as headache occurring on 15 or more days per month, that has evolved in association with the frequent use of acute medication over a period of more than 3 months. Any medication used for the acute treatment of headache can cause MOH.

Diagnosis and management of sleep-related epilepsy in adults

24 Sep 2018Registered users

Nocturnal epilepsies account for 10-15% of all epilepsies, and 80% of nocturnal epilepsies in adults are focal. They present a diagnostic challenge as they can be difficult to differentiate from normal movements and behaviour during sleep and also from several non-epileptic, sleep-related, motor and behavioural disorders. More than 90% of the seizures in sleep-related hypermotor epilepsy (SHE) occur during sleep. Seizures in SHE are simple partial seizures which easily wake the patient so that they will usually be able to recall the seizures, often describing auras of somatic sensations or feeling unable to breathe. SHE seizures have a rapid onset and offset, a short duration (usually < 2 min), and a stereotyped motor pattern for that individual.

 

Special reports

GPs play a vital role in identifying and managing juvenile idiopathic arthritis

24 Sep 2018Registered users

Juvenile idiopathic arthritis (JIA) affects approximately 1-4 per 1,000 children under the age of 16. Girls are more commonly affected than boys. It is a heterogeneous condition, even within JIA categories, ranging from insidious arthritis affecting one to two joints to florid and life-threatening systemic arthritis. All patients with suspected JIA should be referred urgently to a specialist paediatric rheumatology team. Coordinated, multidisciplinary care within a specialist team is required to achieve optimal outcomes.

 

Paediatrics - Temporary access

History taking the key to diagnosing food allergy in children

25 Jul 2018

Allergy to milk and egg are the two most prevalent food allergies in children. They are typically diagnosed in infancy and carry a good prognosis with the majority of cases resolving before the child reaches school age. Other allergies may present later in childhood and are more likely to persist. There is evidence of a causal link between early onset severe and widespread eczema that is unresponsive to moderate topical steroids and development of IgE mediated food allergy, in particular peanut allergy. The EAT study showed that infants who were weaned early and exposed to egg and peanut had a significant reduction in allergy to both foods.



Managing acute asthma in children

25 Jun 2018

The BTS/SIGN guideline specifies that the accurate measurement of oxygen saturation is essential in the assessment of all children with acute wheezing. It recommends that oxygen saturation probes and monitors should be available for use by all healthcare professionals assessing acute asthma in primary care. It is important to use the appropriate size paediatric probe to ensure accuracy. Any patient who presents to the GP practice with any features of a moderate exacerbation should be referred to an emergency department for further assessment and monitoring. 

Be vigilant for depression in children and adolescents

25 Jun 2018

The symptoms of depression in adolescents are similar to those in adults. Depression in children of primary school age may be very subtle and symptoms include mood fluctuations, tearfulness, frustration or temper tantrums. If depression is suspected, it is essential to evaluate the degree of risk. Risk has two key aspects: the likelihood of a potentially harmful incident occurring and degree of potential harm.

Diagnosing and managing sepsis in children

23 Jan 2018

The clinical features of sepsis are: fever; tachycardia, with no other explanation; tachypnoea, with no other explanation; leukocytosis or leucopenia. To meet the International Pediatric Sepsis Consensus Conference definition, a patient should have two of these features, one of which should be fever or abnormal white cell count, in the presence of infection. Every time a child who has symptoms or signs suggestive of infection is assessed, it is important to consider whether this could be sepsis. This may seem obvious in a child presenting with fever, but not all children with sepsis present with high fever or focal signs.

Diagnosing heart disease in children and adolescents

22 Jun 2017

Heart disease in children and adolescents can be congenital, in which structural defects of the heart and major blood vessels are present from birth, acquired, whereby disease develops during life, or genetic, including diseases affecting the heart muscle, electrical system or the aorta. The incidence of congenital heart disease has decreased over the past 30 years, with approximately 1 in 180 babies born with congenital heart disease in the UK each year. Several cardiac diseases are genetic and can manifest in childhood. Most are primary cardiomyopathies, ion channel diseases, coronary artery disease from familial hypercholesterolaemia or aortopathies.

Early referral key to better outcomes in eating disorders

22 Jun 2017

Early recognition, referral and treatment are essential to achieve good outcomes for children and adolescents with eating disorders. Eating disorders have the highest mortality of all psychiatric conditions. However, provided there is access to early and evidence-based treatment, the majority of patients who are diagnosed with an eating disorder before the age of 18 will make a full recovery. Overall, outcomes in this age group are better than in adults. All children and adolescents with a possible eating disorder should be referred to their local specialist community-based eating disorder service for children and young people as soon as possible.

 

A hundred and fifty years ago

150 years ago: Excessive intake of alcohol among the richer classes

24 Sep 2018Registered users

IT IS ESTABLISHED by custom and by the most recent physiological research that alcohol, as such, has its legitimate place in the sustentation both of the healthy and of the diseased organism. However, there is grave danger of excess from the multiplication of alcoholic drinks taken by the richer classes. In this paper, we put the question of the absolute alcoholic allowance for healthy adults in a somewhat crude and abstract form. We do this to compel the upper and middle classes, and their medical advisers, to look the facts of alcoholic consumption honestly in the face.  FE Anstie, Editor of The Practitioner (1868-1874)

 

Editorials

Abstinence and heavy drinking raise risk of dementia

24 Sep 2018Registered users

The risk of dementia in old age is greater in individuals who abstain from alcohol and those who consume more than 14 units per week from midlife than for those who drink moderately, according to findings from a large prospective cohort study. For those drinking > 14 units/week, a 7 unit increase in weekly alcohol consumption was associated with a 17% increase in the risk of dementia.

 

Clinical reviews of research - by GPs with interest

Sulphonylureas and the risk of adverse cardiovascular outcomes

24 Sep 2018Registered users

The use of sulphonylureas as a second-line substitution for metformin in type 2 diabetes is associated with increased rates of myocardial infarction (MI), all cause death and severe hypoglycaemia, a population-based cohort study has found. The study used data from the UK Clinical Practice Research Datalink (CPRD) to analyse a cohort of type 2 diabetes patients retrospectively. The CPRD contains medical records from more than 14 million patients registered at more than 680 general practices.

Labour induction vs expectant management in nulliparous women

24 Sep 2018Registered users

Induction at term significantly reduced the Caesarean section rate, compared with expectant management, in low-risk nulliparous women in a large multicentre trial from the US. However, it did not confer any benefits in terms of perinatal outcomes.

 

HASLAM's view

Seeing eye to eye with other healthcare professionals

24 Sep 2018Registered users

We used to be so insistent that no-one should ever be referred to secondary care unless the referral was made by a GP. It was said with genuine passion. The very idea of an optometrist referring directly to an ophthalmologist was absolute heresy. We needed to be in control. We were the absolute coordinators of the system. We were wrong.

 

CPD exercises associated with each issue

CPD exercise

24 Sep 2018Paid-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 sleep-related epilepsy • Tackling medication overuse headache in primary care • GPs play a vital role in identifying and managing juvenile idiopathic arthritis

 

A hundred years ago

100 years ago: A living fish in the pharynx

24 Sep 2018Registered users

At noon of August 23, 1918, a group of people came to my clinic, carrying a boy, Aboudy Morsi by name, eight years of age, from Talkha, a town on the opposite side of the Damietta branch of the Nile. The boy was nearly dead. The people with him related to me that he was on the Nile, shore fishing. He caught, first, a small trout, which he carried between his teeth, while he had another in his hand.  The first fish glided into his pharynx and lodged there and he was asphyxiated. All this took place half an hour before I saw him.