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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. All articles in The Practitioner online include CPD 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 articles

Improving outcomes in allergic rhinitis in children

24 Jun 2019Registered users

Allergic rhinitis can affect a child’s physical health, reduce their quality of life, sleep and concentration, and impact on school performance. Children with allergic rhinitis are at increased risk of developing asthma. Around 85% of those with asthma have allergic rhinitis, which can complicate diagnosis and management and also increase the risk of hospitalisation for asthma exacerbations. However, appropriate management of allergic rhinitis can improve asthma control. The diagnosis of allergic rhinitis can usually be made on the basis of the patient’s history and examination alone. 

Managing common skin conditions in infants

24 Jun 2019Registered users

Atopic eczema, or atopic dermatitis, affects up to 20% of children and often presents in infancy. Cow’s milk allergy can also manifest as eczema and gastrointestinal (GI) symptoms. Food allergy should be suspected if there is a clear history of a reaction to a food in infants with moderate to severe eczema not responding to standard treatment, in infants with very early onset eczema (under 3 months) and those with GI symptoms. Seborrhoeic dermatitis is often an early manifestation of atopic eczema. Naevus simplex is a common congenital capillary malformation occurring in up to 40% of newborns. Port wine stains are less common, affecting about 0.3% of infants. 

 

Special reports

Prompt detection vital in postpartum mood disorders

24 Jun 2019Registered users

Common mental health disorders affect around one in five women during pregnancy and the first year following childbirth. Depression and anxiety disorders are the most prevalent mental health disorders during this period as they are at other times of life. It is important to distinguish postnatal depression from baby blues, which is common and requires no treatment, although it is a potential risk factor for postnatal depression. Postpartum psychosis affects 1 in 1,000 women and can develop very quickly in the first two weeks postpartum, often requiring urgent admission to a specialised mother and baby unit. One in six women with bipolar disorder will develop postpartum psychosis. 

Managing urinary incontinence in women

22 May 2019Paid-up subscribers

A detailed patient history is key to the assessment of patients with urinary incontinence and to guiding initial investigation and management. Clinical examination should include abdominal palpation to assess for masses, including an enlarged bladder. Visual inspection of the perineum and vagina helps determine whether the patient may be hypo-oestrogenic and can confirm the presence and grading of pelvic organ prolapse. Digital vaginal examination enables detection of masses, and an assessment of pelvic floor muscle strength. Urinalysis should also be carried out. Most patients will have either stress, urgency, or mixed urinary incontinence.

Improving outcomes in obese pregnant women

24 Apr 2019Paid-up subscribers

For obese women the risks of adverse outcomes during pregnancy, for both the mother and her child, are significantly higher than for the general population. In 2016, 21% of all women attending antenatal services in the UK were reported to have a BMI of 30 kg/m2 or higher. In 2003-2005, 27% of all maternal deaths occurred in women with a BMI of 30 kg/mor higher. Obesity increases the risk of venous thromboembolism, gestational diabetes, pre-eclampsia and hypertension. There is an increased likelihood of induction of labour, instrumental delivery and postpartum haemorrhage. The greatest effect on risk reduction is weight loss prior to conception.

 

CPD exercises associated with each issue

CPD exercise - June 2019

24 Jun 2019Paid-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: • Improving outcomes in allergic rhinitis in children • Managing common skin conditions in infants • Prompt detection vital in postpartum mood disorders

 

COPD

Optimising the management of patients with COPD

25 Mar 2019Registered users

COPD should be suspected in an older adult (at least 35 years old but typically more than 45 years old) who presents with symptoms such as breathlessness, wheeze, cough and sputum production and has one or more risk factors, typically current, or a past history of, cigarette smoking. A diagnosis should also be suspected when an individual with a risk factor develops a lower respiratory tract infection requiring treatment. COPD is far more common in smokers of heroin and crack cocaine, in whom it occurs at a younger age.

Pulmonary rehabilitation improves exercise capacity and quality of life

23 Jan 2018Registered users

Pulmonary rehabilitation is a multifaceted programme of exercise and education that aims to improve breathlessness, exercise capacity, and quality of life, and aid self-management. Patients with chronic respiratory failure, those on long-term or ambulatory oxygen and patients with anxiety and depression can all benefit from rehabilitation. It is one of the most beneficial and cost-effective treatments for COPD and should be considered a fundamental component of disease management rather than an option.

Improving outcomes in COPD

23 Nov 2017Registered users

Cigarette smoking is overwhelmingly the most important risk factor for COPD. In some cases, other factors such as occupation, passive exposure to inhalants and fetal nutrition/low birthweight are also important. The diagnosis should be suspected in symptomatic patients with risk factors, usually cigarette smoking, aged 40 years or above, albeit a majority of people with COPD present when considerably older. The 2017 GOLD guideline recommends that management should be focused on two objectives. First, to relieve symptoms of breathlessness (assessed using the MRC dyspnoea scale) and improve quality of life (assessed by the COPD Assessment Test). Second, to reduce risk assessed by the number of exacerbations and hospitalisations in the previous year.

 

Cardiovascular disease

Managing arrhythmias in coronary artery disease

23 Jan 2019Registered users

A detailed history is essential in patients with coronary artery disease (CAD) to elucidate red flag symptoms necessitating urgent specialist assessment. Red flags include syncope and presyncope, particularly in patients with concomitant left ventricular systolic dysfunction. Palpitations with severe chest pain and breathlessness also warrant urgent assessment. Undiagnosed atrial fibrillation (AF) is common in older populations. LVEF of 35% or less is a predictor of increased risk of sudden death. All patients with CAD should therefore undergo assessment of LVEF, usually by transthoracic echocardiography.

Managing stable angina in primary care

22 Oct 2018Paid-up subscribers

Around 50% of people diagnosed with ischaemic heart disease present with stable angina as the first symptom. The likelihood of a diagnosis of angina increases with the number of cardiovascular risk factors present. A resting 12-lead ECG is recommended for all patients with suspected angina. However, a normal result does not exclude the presence of underlying coronary artery disease.

Diagnosing heart disease in children and adolescents

22 Jun 2017Paid-up subscribers

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.

 

Dermatology

Improving detection of non-melanoma skin cancer

05 Aug 2015Registered users

Basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) are clinically and pathologically distinct and both are locally invasive. However, while BCCs rarely metastasise, SCCs have the potential to do so especially when they arise on the ears or lips. Patients with one non-melanoma skin cancer (NMSC) have a higher risk of developing another NMSC and of malignant melanoma.

GPs have key role in early detection of melanoma

24 Jun 2013Registered users

Lesions which have a high index of suspicion for melanoma should not be removed in primary care. Patients should be referred urgently to secondary care with a history recording the duration of the lesion, change in size, colour, shape and symptoms. 

 

Editorials

Direct oral anticoagulants reduce all-cause mortality in AF

24 Jun 2019Registered users

Direct oral anticoagulant (DOAC) therapy in patients with non-valvular atrial fibrillation (AF) was associated with a significantly lower risk of death compared with no anticoagulation, in a retrospective cohort study, published in Heart. In this cohort of newly diagnosed patients with moderate- to high-risk non-valvular AF treated in routine clinical practice, DOAC therapy was associated with a 31% reduction in all-cause mortality.

 

Research reviews - by GPs with a special interest

Antiretroviral treatment in gay men minimises risk of HIV transmission

24 Jun 2019Paid-up subscribers

There is effectively zero risk of HIV transmission in gay men through condomless sex when HIV viral load is adequately suppressed, the findings of the PARTNER2 study, published in the Lancet, suggest.

Benefits of quitting smoking outweigh the risks of weight gain

24 Jun 2019Paid-up subscribers

The cardiovascular and overall mortality benefits of stopping smoking far outweigh the risks of weight gain and acquiring type 2 diabetes, a study from the United States has shown.

Controlling risk factors in type 2 diabetes reduces excess risk

24 Jun 2019Paid-up subscribers

Patients with type 2 diabetes who have well controlled risk factors have little or no excess risk of stroke, myocardial infarction or death, a retrospective cohort study has found.

Tramadol associated with longer use of opioids after surgery

24 Jun 2019Paid-up subscribers

A study from the United States has found that patients prescribed tramadol for postoperative pain have a higher risk of prolonged opioid use relative to those given other short-acting opioids.

 

HASLAM's view

Was I technically right but morally wrong?

24 Jun 2019Registered users

It’s a case that still bugs me. One that I honestly think I mishandled. Scientifically I was 100% correct. However, I still think I got it wrong. I believed myself to be a kind and compassionate doctor. I also knew and understood the science, and the importance of optimising my time. Would getting out of bed to drive to this patient, sitting with her for 20 minutes, being kind and understanding, have been the right thing to do?

 

Lead clinical reviews of 2019

Do 5 alpha-reductase inhibitors raise the risk of type 2 diabetes?

22 May 2019Registered users

Finasteride and dutasteride appear to be associated with a modest increase in the risk of developing type 2 diabetes, according to the findings of a retrospective cohort study.

Regular cannabis use raises risk of psychosis

24 Apr 2019Registered users

Daily cannabis use is associated with a three-fold increased risk of psychotic disorder, a multicentre, international case-control study has shown.

Does intensive BP lowering reduce risk of dementia?

25 Mar 2019Registered users

Intensive blood pressure (BP) control reduces the risk of developing mild cognitive impairment, but not dementia, a US randomised trial has found.

 

A hundred and fifty years ago

150 years ago: Surgical practice during the siege of Paris

24 Jun 2019Registered users

During the Siege of Paris wounds were of exceptional gravity. Older surgeons, who had had much experience in wars, admitted that the wounds during the siege were of unexampled and unprecedented fatality. In cases I had observed a violent contusion of the marrow extending very high up; it was obvious to me that this marked injury was of immediate origin. At the same time, the bones themselves presented the most serious lesions; there was splitting and splintering of the bone, extending as high up as the great trochanter, for instance, in cases of fractured femur. Amputation was, at the beginning, universally employed. The results were disastrous, the mortality was absolute and general. Most strenuous exertions were made by Paris surgeons, and were much insisted on by myself, in the direction of conservative surgery in wounds which engaged the bones, and particularly the femur.

 

A hundred years ago

100 years ago: The mental condition preceding suicide

24 Jun 2019Registered users

The general practitioner  is often puzzled to know how to deal with a case in which suicide is frequently threatened,  but, provided his diagnosis of an anxiety neurosis is correct, it is probably better to treat these cases by psychotherapeutic methods, and take the slight risk of suicide than adopt such a course as warning and consequently scaring the relatives, or advising a constant attendant or admission to an institution, for such steps are often productive of more harm than good. On the other hand, in manic depressive conditions and paranoia, the risk of suicide is real and ever present. Too great watchfulness cannot be exercised, and such patients should only be sent to institutions for the treatment of mental diseases where the condition is fully understood and effective precautions are taken; for it is remarkable what cunning will be displayed, even by an apparently stuporous melancholic, to elude the vigilance of his attendants and seize an opportunity to kill himself.