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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

Diagnosing heart disease in children and adolescents

22 Jun 2017Registered users

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 2017Registered users

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.

 

Special reports

Aerobic exercise can improve sleep and pain in fibromyalgia

22 Jun 2017Registered users

Fibromyalgia is a chronic condition characterised by regional pain at multiple sites, non-restorative sleep and fatigue. In the UK, it is a common cause of musculoskeletal pain and significant disability, affecting around 2% of the population. It has a female preponderance with a female to male ratio of 7:1. Self-help strategies are important. There is strong evidence of benefit from a slow graded increase in daily aerobic exercise which can increase delta sleep and restore descending pain inhibition mechanisms. Sleep hygiene should also be considered to promote delta sleep.

Early referral improves long-term outcomes in rheumatoid arthritis

23 May 2017Registered users

Rheumatoid arthritis is a common, chronic systemic inflammatory disease of unclear aetiology leading to synovial hypertrophy and joint inflammation. It typically presents with symmetrical polyarthritis of small joints of the hands or feet, but can also involve larger joints, and have associated extra-articular manifestations. Diagnosis is based on duration of symptoms, joint distribution, level of inflammatory markers and autoantibodies. The presence of synovitis or effusion is essential for diagnosis. Early referral of patients with suspected synovitis results in significant improvements in long-term outcomes.

 

Clinical reviews of research - by GPs with interest

Risk of suicide in university students double that of graduates

22 Jun 2017Registered users

Compared with those who have completed university education, university students are more than twice as likely to commit suicide, a Swedish study has found.

Termination of pregnancy via telemedicine service safe and effective

22 Jun 2017Registered users

Women using an online telemedicine service for medical termination of pregnancy (MTOP) reported good outcomes, a study has found.Women using an online telemedicine service for MTOP reported good outcomes, a study has found. The study authors analysed data on all women from the Republic of Ireland and Northern Ireland who contacted the Women on Web telemedicine helpdesk, between January 2010 and December 2012. (In both countries termination is not available through the formal healthcare system except in restricted circumstances).

 

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: editor@thepractitioner.co.uk

Case reports

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

24 Apr 2017

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

Dreams 3: Dreams and crime

22 Jun 2017Paid-up subscribers

WHAT IS THE ASSOCIATION of dreams with crime? I have questioned insane criminals about their dreams in connection with specific crimes, and although there is always some reserve about admitting revelations in connection with criminal acts, I find that they dream much as do other people. In this class, there is a considerable difficulty in proving their hidden personal secrets, and in overcoming the resistance of the so-called “censor”.

Dreams 2: Prophetic dreams

23 May 2017Paid-up subscribers

MANY PERSONS have endeavoured to read into dreams some hidden meaning whilst others consider them to be only a confused and jumbled record of sleep-memories unworthy of serious reflection. Possibly the truth in regard to dreams lies between these two extremes of undue scepticism and a too facile credence.

 

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

 

Editorials

Cognitive deficits and awareness of hypoglycaemia in type 1 diabetes

22 Jun 2017Registered users

A study of patients with type 1 diabetes has shown an association between impaired awareness of hypoglycaemia and cognitive deficits such as diminished learning, memory and pattern separation. This study compared cognitive function in type 1 diabetes patients who had normal awareness of hypoglycaemia with patients who had impaired awareness of hypoglycaemia. The study authors state: ‘It is possible that people with impaired awareness of hypoglycaemia have a diminished ability to distinguish cues that are specifically associated with hypoglycaemia and hence are unable to take appropriate action to avoid severe hypoglycaemia.'

Job strain may precipitate clinical depression

23 May 2017Registered users

Job strain, a combination of high demand and low control, is associated with an increased risk of subsequent clinical depression, a meta-analysis has found. Patients who report stress at work are both more likely to be depressed and more likely to become depressed. In the UK in 2015/16, work-related stress accounted for 37% of work-related ill health and 45% of working days lost. When helping patients get back to work it is important to discuss ways of reducing job strain and the demand control support model provides a helpful framework.

Practice nurses can improve insulin uptake in type 2 diabetes

24 Apr 2017Registered users

Achieving and maintaining glycaemic targets early on in type 2 diabetes has been shown to improve long-term outcomes. Delay in stepping up treatment, especially initiating insulin therapy is known to be a problem in primary care. A primary care study from Australia, in which practice nurses were trained to have an enhanced role, has shown improved rates of safe and effective insulin initiation compared with usual care.

 

HASLAM's view

Do surgeons or GPs take the greatest risks?

22 Jun 2017Registered users

Ask ten thousand people which they think is the riskiest – surgery or general practice – and the only ones who will answer general practice will be surgeons or GPs. To the vast majority of the population, the drama of surgery looks horrifically risky. The drama of general practice may not be as great as it is for those who skilfully wield a scalpel while working medical and surgical miracles. However, a life that is saved by early diagnosis is just as much a life as one that is rescued from a life-threatening event.

 

CPD exercises associated with each issue

CPD exercise - June 2017

22 Jun 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: • Diagnosing heart disease in children and adolescents • Early referral key to better outcomes in eating disorders • Aerobic exercise can improve sleep and pain in fibromyalgia

CPD exercise - May 2017

23 May 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: • Be vigilant for dementia in Parkinson’s disease • Diagnosing and managing mild cognitive impairment • Early referral improves long-term outcomes in rheumatoid arthritis