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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

Regular review pivotal in chronic asthma in children

23 Nov 2017Registered users

The aim of asthma treatment is complete control of symptoms as soon as possible while minimising side effects and inconvenience to the patient. All parents and older children should be offered a written action plan. This should include details of the patient’s regular medicines, how to recognise deterioration and what to do in the event of an attack. Children should be referred to secondary care if: the diagnosis is unclear; control remains poor despite monitored treatment; they have suffered a life-threatening attack or red flag features are present.

Improving outcomes in COPD

23 Nov 2017Paid-up subscribers

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.

Improving uptake of cardiac rehabilitation

23 Oct 2017Registered users

Data from the National Audit of Cardiac Rehabilitation show that 50% of eligible MI, PCI, and CABG patients do attend cardiac rehabilitation and that figure continues to rise, but the rates for stable angina and heart failure remain low. There is evidence that programmes which have a basis in psychoeducation (goal setting, self-monitoring, relapse prevention) are more likely to achieve long-term behaviour change than those based simply on delivering a fixed agenda of exercise and education. A recent Cochrane review of exercise-based cardiac rehabilitation continues to show the benefit of exercise prescription in terms of cardiovascular mortality, hospital readmission rates, and quality of life.

Assessment and management of CVD risk in adults

23 Oct 2017Registered users

Cardiovascular disease (CVD) affects seven million people in the UK alone. CVD is a term that encompasses coronary heart disease, atrial fibrillation, aortic disease, peripheral artery disease and stroke. Modifiable risk factors for CVD include smoking, abnormal lipid profile, hypertension, diabetes, abdominal obesity, psychosocial factors, diet, alcohol consumption, and lack of physical activity. The INTERHEART study concluded that these factors account for more than 90% of the risk of MI worldwide. Well validated studies have suggested that QRISK2 is a better predictor of a patient’s ten-year risk of CVD compared with the traditionally used Framingham equation.

 

Special reports

Have a high index of suspicion for sepsis in primary care

23 Oct 2017Registered users

The incidence of sepsis in the UK is estimated at 200,000 cases a year. Around 70% of cases of sepsis originate in the community. Most infections are self-limiting and can be managed outside hospital. However, patients with sepsis will deteriorate rapidly and each hour of delay to antibiotic administration is linked to decreased survival by 7.6%. Infants (< 1 year) and the elderly (> 75 years) seem to be far more likely to progress to sepsis than others. The assessment of sepsis in primary care should be standardised and include measurement of temperature, heart rate, respiratory rate, blood pressure, level of consciousness and oxygen saturation in young people and adults.

Diagnosing childhood eczema can be challenging

25 Sep 2017Registered users

Atopic eczema is the most common endogenous type of eczema in infants and children and affects around 15-20% of school-age children in the UK. Its prevalence is highest in children under the age of two and subsequently diminishes with age. It has a chronic, relapsing course. An emergency referral to a dermatologist or paediatrician should be made via telephone when there is a suspicion of eczema herpeticum or eczema coxsackium. Other indications for referral include diagnostic uncertainty, recurrent secondary infection, when control remains poor despite topical treatments, and for patients with emotional distress or significant sleep disturbance.

 

Clinical reviews of research - by GPs with interest

Depression in midlife does not raise risk of dementia

23 Oct 2017Registered users

Depression may be a prodromal feature of, rather than a risk factor for, dementia, a UK prospective cohort study has found. A total of 10,308 participants (6,895 men) in the Whitehall ll study, aged 35-55 at recruitment, were followed up between 1985 and 2015. 

Moderate alcohol consumption may affect cognitive function

22 Sep 2017Registered users

Even moderate alcohol consumption, compared with abstinence, may raise the risk of hippocampal atrophy and faster decline in lexical fluency, an analysis of data from the Whitehall ll study has found.

 

Case report submission

Do you have an interesting case that you would like to share with readers? Your article would need to be around 1,500 words long, include a brief review of the literature to put the case in context, and be fully referenced in the Vancouver style.Submissions for consideration for publication should be sent to: [email protected]

Case reports

Palpitations: when you hear hoof beats don’t forget to think zebras

24 Apr 2017Registered users

In general practice palpitations are reported in around 8 per 1,000 persons per year. The differential diagnosis includes cardiac and psychiatric causes, as well as numerous others e.g. anaemia, hyperthyroidism, prescribed medication, caffeine and recreational drugs. Factors that point towards a cardiac aetiology are male sex, irregular heartbeat, history of heart disease, event duration > 5 minutes, frequent palpitations, and palpitations that occur at work or disturb sleep.

Artefact mimicking torsades: treat the patient not the ECG

22 Feb 2017Registered users

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.

 

A hundred years ago

Gonococcus infection in women

23 Oct 2017Registered users

It seems to have been established beyond doubt that about 70 per cent of the inflammatory affections met with in married women are due to infection by the gonococcus. The reason why the disease is so common in women, who do not, in many instances, know what they are suffering from, is because they have been infected immediately after marriage by their husbands who are suffering from the effects of the disease, and who have imagined themselves cured and ready for marriage.

Malingering or hysteria?

22 Sep 2017Registered users

“His history showed he had been wounded in the head in the retreat from Mons and sent home. On account of these fits he had been discharged from the army. There was no epileptic history in the family and organically he was sound. He told me he had had these fits since he returned wounded, but that before that he was perfectly well”

 

Editorials

Patients with paroxysmal AF at risk of stroke are undertreated

23 Oct 2017Registered users

Patients with paroxysmal atrial fibrillation (AF) eligible for anticoagulation are still less likely to receive anticoagulants than those with persistent or permanent AF, a UK study has found. Both national and European guidelines recommend that anticoagulants are offered to all patients with AF at increased risk of stroke, irrespective of the type of AF. Even in 2015 patients with paroxysmal AF eligible for anticoagulation were still almost 20% less likely to have these drugs prescribed than those patients with persistent or permanent AF.

Does metformin lower CVD risk in type 2 diabetes?

28 Sep 2017Registered users

A recent meta-analysis to evaluate the impact of metformin on cardiovascular disease has been unable to demonstrate convincingly that it is associated with a reduction of risk. The investigators searched Medline, Embase and the Cochrane Library for relevant papers in all languages.  The final yield was ten articles, reporting 13 trials of metformin, virtually all carried out in Northern Europe or North America. In total, 2,079 patients with type 2 diabetes were allocated to metformin and a similar number to comparison groups. All the outcomes, with the exception of stroke, favoured metformin but none achieved statistical significance.

 

Temporary access

Have a high index of suspicion for meningitis in adults

01 Aug 2016

Bacterial meningitis and meningococcal sepsis are rare in adults. Any diagnostic delays with subsequent delay to treatment can have disastrous consequences. The classic triad of neck stiffness, fever and altered consciousness is present in < 50% of cases of bacterial meningitis. Patients with viral meningitis also present with signs of meningism (headache, neck stiffness and photophobia) possibly with additional non-specific symptoms such as diarrhoea or sore throat. Suspected cases of meningitis or meningococcal sepsis must be referred for further assessment and consideration of a lumbar puncture.

 

HASLAM's view

A salutary tale of one man and his dog

23 Oct 2017Registered users

He had been admitted to hospital because his diabetes had slipped hopelessly out of control. The experts were baffled. It was fascinating listening to all the great minds at the teaching hospital trying to fathom out why this had happened. However, the discussion was going nowhere until a dishevelled figure in the audience put his hand up. ‘Excuse me,’ he said. ‘You’re all forgetting about his dog.’ The great and the good shifted with embarrassment and tried to avoid his eyes. 

Gratitude and survival are not evidence of effectiveness

28 Sep 2017Registered users

I sometimes suspect that everything that I learnt at medical school will one day be proved to have been wrong. When it comes to therapeutics and management, then few drugs or theories ever survive the onslaught of new research. This is almost certainly a good thing, however frustrating it might seem when we have to try to keep up. We need high quality evidence to ensure that we don’t keep on making the same mistakes with ever increasing confidence. Simply believing that something works, and having stories of grateful patients, can never be sufficient.

 

CPD exercises associated with each issue

CPD exercise - October 2017

23 Oct 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: • Assessment and management of CVD risk in adults • Improving uptake of cardiac rehabilitation • Have a high index of suspicion for sepsis in primary care

 

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

Inherited disorders

22 Feb 2016Registered users

• Darier’s disease • Diffuse palmoplantar keratoderma • Familial hypercholesterolaemia • Neurofibromatosis type 1 • Haemophilia A • Epidermolysis bullosa simplex

Skin conditions in children

25 Jan 2016Registered users

 • Classic spitz naevus •  Irritant saliva dermatitis •  Umbilical granuloma •  Cradle cap •  Molluscum contagiosum •  Juvenile plantar dermatosis