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The Practitioner

The Practitioner is a PubMed indexed journal, 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

Be vigilant for dementia in Parkinson’s disease

23 May 2017Registered users

It is estimated that up to 80% of patients with Parkinson’s disease will eventually develop cognitive impairment over the course of their illness. Even at the time of diagnosis, cognitive impairment has been reported in 20-25% of patients. Commonly affected domains are executive function, visuospatial ability and attention control. In addition, patients with Parkinson’s disease dementia may present with deficits in language function and verbal memory.

Diagnosing and managing mild cognitive impairment

23 May 2017Registered users

The prevalence of mild cognitive impairment in adults aged 65 and over is estimated to be 10-20%. It is likely that this figure will increase in line with trends in dementia diagnosis. In some cases, mild cognitive impairment may be a prodrome for dementia, and may be caused by any of the dementia pathology subtypes. It is important to obtain a history of cognitive changes over time, as well as information about the onset and nature of cognitive symptoms, confirmed by a reliable informant, if available.

Diagnosing testicular lumps in primary care

24 Apr 2017Paid-up subscribers

Although the incidence of testicular cancer has increased over the past few decades, testicular tumours are still rare and many GPs will only see one or two new diagnoses in their career. When examining scrotal swellings, the key question is whether the lump is intra- or extra-testicular, as palpable intra-testicular lesions are highly likely (around 90%) to be malignant, whereas those lying outside the testis are usually benign.

Diagnosing and managing androgen deficiency in men

24 Apr 2017Paid-up subscribers

Androgens play a crucial role in bone, muscle and fat metabolism, erythropoiesis and cognitive health. In men aged 40-79 years the incidence of biochemical deficiency and symptomatic hypogonadism is 2.1-5.7%. Decreased libido or reduced frequency and quality of erections, fatigue, irritability, infertility or a diminished feeling of wellbeing may be presenting complaints. However, a significant proportion of men with androgen deficiency will be identified when they present for unrelated concerns.

 

Special reports

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.

Improving pain control in diabetic neuropathy

22 Mar 2017Paid-up subscribers

Diabetic neuropathy is thought to affect 1.9% of the world’s population and 50% of patients with a diagnosis of diabetes mellitus which would equate to 2.25 million people in the UK. The term diabetic neuropathy includes multiple distinct clinical entities that have been classified under the broad headings of focal and multifocal neuropathies and symmetrical neuropathies. Peripheral diabetic neuropathy, a chronic distal symmetrical predominantly sensory neuropathy, is the most common form of diabetic neuropathy. The common presentation is of painful symptoms originating in the feet, that then spread to the knees before involving the distal portion of the upper limbs in a ‘glove and stocking’ distribution.

 

Clinical reviews of research - by GPs with interest

Gestational diabetes is on the increase

23 May 2017Paid-up subscribers

The prevalence of gestational diabetes mellitus (GDM) has been increasing over the past three decades, a large retrospective cohort study from the US has shown.

Heavy drinkers and teetotallers at increased risk of wide range of cardiovascular diseases

23 May 2017Registered users

Both high levels of alcohol consumption and abstinence raise the risk of a broad spectrum of cardiovascular disorders, a UK study has shown.

Insulin pumps vs multiple injections in adults with type 1 diabetes

23 May 2017Registered users

A randomised controlled trial comparing insulin pump use with multiple daily injections suggests that when patients are engaged with intensive self-management, insulin pump therapy may not add significant extra benefits in adults.

Non-major bleeds less frequent in AF patients on apixaban

23 May 2017Paid-up subscribers

Non-major bleeding was substantially less in patients on apixaban compared with those on warfarin in the Apixaban for Reduction in Stroke and other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial. 

Gene variants associated with increased risk of congenital heart defects with SSRI use

24 Apr 2017Paid-up subscribers

Common variants in genes related to folic acid, homocysteine and glutathione/transsulfuration metabolic pathways are associated with an increased risk of congenital heart disease in the offspring of women who take SSRIs in the periconceptual period, a US case control 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: 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.

 

A hundred years ago

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.

Dreams 1:Dreams, insanity and fear

24 Apr 2017Paid-up subscribers

IT MAY SEEM OUT OF PLACE that we should be discussing the realms of dreamland, whilst we are face to face with so grim a reality as a War for our very existence; a War which has so deeply affected the life of every individual in this country as well as within the Empire. But we may claim that the “Bowman” in the early days of the War laid particular emphasis upon dreams — for to these of our brave warriors appeared the “Angel of the Mons,” and the “unconscious mind” has thus been drawn, in literature at any rate, into the tragedies of the War. [Written in 1917 in The Practitioner

 

Editorials

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

If I knew then what I know now…

23 May 2017Paid-up subscribers

Directly in front of me sat a woman whose neck I can picture perfectly even after all these years. It was the suspicious looking lesion just below her hairline that had caught my attention. I felt it could well be a malignant melanoma. What should I do?

 

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

 

CPD exercises associated with each issue

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

CPD exercise - April 2017

24 Apr 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 testicular lumps in primary care • Diagnosing and managing androgen deficiency in men • Palpitations: when you hear hoof beats don’t forget to think zebras