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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

Detecting obstructive sleep apnoea hypopnoea syndrome

24 Oct 2019Registered users

Obstructive sleep apnoea hypopnoea syndrome (OSAHS) is characterised by repeated episodes of partial or complete collapse of the upper respiratory passages, mainly the oropharyngeal tract, during sleep. Obesity is the strongest risk factor for OSAHS; other risk factors include smoking, excessive drinking, sedatives and hypnotics. Habitual snoring, unrefreshing sleep and daytime somnolence suggests the possibility of OSAHS. When this is combined with a partner’s account of nocturnal apnoeas or snoring pauses the diagnosis becomes highly likely. However, negative screening results or the absence of clinical features by themselves should not be used to rule out OSAHS.

Improving COPD outcomes in primary care

24 Oct 2019Registered users

Diagnosis of COPD is based on the presence of airflow obstruction after the administration of a bronchodilator i.e. post-bronchodilator spirometry. However, the National COPD Audit report for 2017-18 found that 59.5% of people hospitalised with a COPD exacerbation in England and Wales had no spirometry result available and in 12% of those who had undergone spirometry the test showed no airflow obstruction. Patients with COPD should be reviewed annually. It is advisable to repeat spirometry if there is a significant change in symptoms. It is important to determine objective measures of breathlessness (MRC dyspnoea score), quality of life (CAT questionnaire) and exacerbations (annual exacerbation and hospitalisation rate) as part of this review.

 

Special reports

Epidermolysis bullosa requires lifelong monitoring

24 Oct 2019Paid-up subscribers

Epidermolysis bullosa (EB) arises from mutations within genes encoding for different proteins which contribute to the structural integrity of the epidermis and basement membrane zone. There are four major EB types: EB simplex (EBS), dystrophic EB (DEB), junctional EB (JEB) and Kindler syndrome. The main cutaneous features of inherited EB are mechanical fragility of the skin and formation of blisters and erosions with minimal trauma. The initial diagnosis of EB is based on the patient’s personal and family history and examination. Skin biopsies are taken from newly induced blisters to identify the level of skin cleavage which helps to determine the subtype.

Diagnosing and managing dementia in primary care

25 Sep 2019Registered users

In patients with suspected dementia, the history should cover cognitive, behavioural and psychological symptoms, and the impact symptoms have on daily life. A physical examination is necessary to look for any focal neurological signs and to exclude any visual or auditory problems. Baseline blood tests should be carried out. A medication review should be undertaken as many commonly prescribed drugs have anticholinergic effects which can exacerbate cognitive impairment. A brief cognitive screening test should be performed before referral to a memory clinic.

 

Research reviews - by GPs with a special interest

Flu vaccination reduces all-cause mortality in heart failure patients

24 Oct 2019Paid-up subscribers

Influenza vaccination was associated with a significantly lower risk of all-cause mortality in patients with heart failure, a meta-analysis has found. However, the effect on cardiovascular deaths and hospitalisations was not significant.

Breathlessness independently associated with obesity and weight gain in adult life

24 Oct 2019Paid-up subscribers

Middle-aged individuals with a high body mass index (BMI) and those whose BMI had significantly increased since the age of 20 had an increased prevalence of breathlessness, a population-based study has found.

Incidence of type 2 diabetes varies markedly between occupations

24 Oct 2019Paid-up subscribers

Men employed as professional drivers, and manufacturing or agricultural workers were three times more likely to develop type 2 diabetes compared with university teachers and architects, in a national study from Sweden.

Gonorrhoea may be transmitted by kissing in men who have sex with men

24 Oct 2019Paid-up subscribers

Men who have sex with men (MSM) may transmit oropharyngeal gonorrhoea to partners by kissing, a cross-sectional study from Australia has found.

 

CPD exercises associated with each issue

CPD exercise - October 2019

24 Oct 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: • Detecting obstructive sleep apnoea hypopnoea syndrome • Improving COPD outcomes in primary care • Epidermolysis bullosa requires lifelong monitoring

 

Paediatrics

Childhood asthma peaks at the start of the school year

25 Sep 2019Registered users

Asthma exacerbations increase in children under 15 years, especially boys, when children return to school in September after the summer holidays, a UK study has found. The adjusted daily rate of GP in-hours asthma consultations in children was 2.5 to 3 times higher in the back to school excess period than in the baseline period.

Managing acute asthma in children

25 Jun 2018Paid-up subscribers

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. 

Diagnosing and managing sepsis in children

23 Jan 2018Registered users

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 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.

 

Editorials

Suicide risk in doctors

24 Oct 2019

Male doctors have a lower suicide risk than the general male population, an analysis of English death registrations from 2011 to 2015 has found. However, the risk for female doctors is comparable with that of the general female population, although the male preponderance of suicide meant that there were in fact more than twice as many male as female doctor suicides. There are differences between specialties: compared with physicians, GPs are more than three times as likely to commit suicide.

Childhood asthma peaks at the start of the school year

25 Sep 2019Registered users

Asthma exacerbations increase in children under 15 years, especially boys, when children return to school in September after the summer holidays, a UK study has found. The adjusted daily rate of GP in-hours asthma consultations in children was 2.5 to 3 times higher in the back to school excess period than in the baseline period.

 

HASLAM's view

How can GPs prevent burnout?

24 Oct 2019

It is still possible to do the same job, at the same desk, with the same patients for more than 35 years. For many, this alone will be an immensely rewarding life, linked to a community and with the satisfaction of genuine long-term continuity of care. However, for others, it can be a recipe for burnout and disillusionment.

 

A hundred and fifty years ago

150 years ago: An indication for nitrite of amyl

24 Oct 2019

AT TWELVE O’CLOCK ON THE NIGHT of October 23, 1870, a woman begged I would instantly go and see her daughter, who, she said, ‘was in a dying state.’ On entering her bedroom, I saw the patient, a young married woman, half undressed, sitting on the corner of the bed and holding on to the bed-post. There was a dusky leaden hue about her face, neck, chest, and hands, and a cold damp sweat clung to her. Her body generally was cold, but her feet and legs were of an icy coldness. Her pulse could scarcely be felt. She was making violent efforts to breathe, and each inspiration was accompanied with marked recession of the supra-clavicular and the intercostal spaces. Loud sibilant rales with sonorous rhonchus could be heard over the greater part of the chest.  She tried to speak, but could only make faint gasps.

150 years ago: Spectral illusions due to physical disorder

25 Sep 2019

An old widow woman, living in a retired village, came one day to the parson of the parish in a state of great despondency. She said she had had 'a signal warning,' and she was sure she would soon be in her grave, for she was continually haunted by 'a skeleton'. The parson having in vain tried to convince her that she was under a delusion, set about a systematic examination of her eyes.

 

A hundred years ago

100 years ago: Influenza and public health

24 Oct 2019Registered users

IN JANUARY 1907, I contributed  an article to the Special Influenza Number of The Practitioner. In 1919 it must be admitted that for actual control over influenza we are practically no further advanced than in 1907. Nor are we much further advanced in our knowledge of the bacteriology of influenza. We have no knowledge whether the pandemics of the past mean the excitation in microbes always with us, or increased pathogenicity and greater striking-power, or the introduction of an equally mysterious virus from some unknown centre or centres.

100 years ago: Incontinence cured by electrical methods

25 Sep 2019Registered users

About this time, it occurred to me that in children enuresis often ceases spontaneously about puberty – i.e., among other things coincidentally in the development of the prostate. I determined to stimulate this organ electrically in incontinent young men and chose a high-frequency condenser electrode for the purpose. It consisted of a small test tube, filled with water, and corked. Through the cork was thrust a stiff wire, having a loop on the outside for attachment to the lead from the solenoid. The test tube was vaselined and introduced about 2 to 3 inches into the rectum. It was then connected with the generator, and the high-frequency current turned on for 15 minutes. The treatment was given daily. An improvement in results was very soon evident. Cures rose from 25 to 60 per cent