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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 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

Tailoring dialysis modality to the patient

22 Feb 2019Paid-up subscribers

End stage renal disease can be defined as the requirement for kidney transplantation or dialysis therapy. In the UK in 2016, of the 63,162 people receiving renal replacement therapy 53% were renal transplant recipients, 41% were on haemodialysis and 6% were on peritoneal dialysis. Dialysis should be started when: symptoms of uraemia impact on day to day living; the need is indicated by biochemical measures or uncontrollable fluid overload or at an eGFR of 5-7 ml/min/1.73 m2 in the absence of symptoms. The choice of dialysis modality is influenced by the individual’s functional status, social circumstances and confidence.

Management and prevention of renal and ureteric stones

22 Feb 2019Registered users

Kidney stones are common with as many as 1 in 10 people developing a symptomatic stone. Up to 50% of stone formers will have at least one further symptomatic stone in their lifetime. Ureteric colic is unaffected by posture with patients often writhing in seemingly futile attempts to relieve pain. Immediate management comprises effective analgesia while urinalysis is the first step in confirming the diagnosis. One of the challenges facing the GP is to differentiate patients who warrant immediate hospital referral from those who can be seen less acutely.

 

Special reports

Optimising outcomes in chronic heart failure

22 Feb 2019

Although patients can present with non-specific symptoms and minimal clinical signs, generally, in the community, patients with heart failure present with symptoms of dyspnoea or fluid retention. In order to confirm (or refute) the diagnosis, NICE recommends natriuretic peptide testing (ideally N-terminal pro B-type natriuretic peptide; NT-proBNP) in all patients with suspected heart failure. An NT-proBNP level > 2,000 ng/L is highly suggestive of heart failure and NICE recommends echocardiography and specialist review within 2 weeks. Conversely, an NT-proBNP level < 400 ng/L suggests that a diagnosis of heart failure is unlikely. Patients with an NT-proBNP of 400-2,000 ng/L should have echocardiography and specialist assessment within 6 weeks.

Investigating the underlying cause of erectile dysfunction

23 Jan 2019Registered users

Rates of erectile dysfunction (ED) increase with age, with an estimated 70% of men aged 70 affected to some extent. ED is a significant predictor of underlying cardiovascular disease. In addition to the onset and duration of symptoms, important points in the history to clarify are: how the patient defines their ED, whether they have ever had erectile function, whether morning erections are preserved, the context of ED and recent sexual history. Men should be asked about symptoms of hypogonadism such as loss of libido or low energy levels. Cardiovascular risk should be evaluated.

 

CPD exercises associated with each issue

CPD exercise - February 2019

22 Feb 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:• Management and prevention of renal and ureteric stones • Tailoring dialysis modality to the patient • Optimising outcomes in chronic heart failure

 

Paediatrics

GPs play a vital role in identifying and managing juvenile idiopathic arthritis

24 Sep 2018Registered users

Juvenile idiopathic arthritis (JIA) affects approximately 1-4 per 1,000 children under the age of 16. Girls are more commonly affected than boys. It is a heterogeneous condition, even within JIA categories, ranging from insidious arthritis affecting one to two joints to florid and life-threatening systemic arthritis. All patients with suspected JIA should be referred urgently to a specialist paediatric rheumatology team. Coordinated, multidisciplinary care within a specialist team is required to achieve optimal outcomes.

Regular review pivotal in chronic asthma in children

23 Nov 2017Paid-up subscribers

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.

Early intervention crucial in anxiety disorders in children

23 Jun 2016Paid-up subscribers

Anxiety disorders are among the most common mental health disorders of childhood. Three quarters of anxiety disorders have their origins in childhood, with presentation often chronic in nature. Where the child is experiencing significant distress or functional impairment (e.g. missing school, not taking part in age-appropriate activity), then specialist input is likely to be needed.

 

Women's health

Early treatment vital in pelvic inflammatory disease

23 Apr 2018Registered users

Pelvic inflammatory disease (PID) is caused by infection ascending from the cervix. It can affect the uterus, fallopian tubes, ovaries, and peritoneum. Important sequelae include infertility, ectopic pregnancy and tubo-ovarian abscess. PID is associated with sexually transmitted infections. These are more prevalent in younger women. A diagnosis of PID should be considered in any sexually active woman with recent onset pelvic pain associated with tenderness on bimanual examination where other differentials have been excluded. Delay in commencing treatment for PID has been shown to increase the risk of long-term complications.

Tailor management to the patient with fibroids

22 Mar 2017Paid-up subscribers

Fibroids are benign, hormone-dependent tumours of uterine smooth muscle and connective tissue. They are commonly asymptomatic, but can cause symptoms such as heavy menstrual bleeding and pelvic pressure symptoms. Around 20 to 30% of women with heavy menstrual bleeding have fibroids. Fibroids are most prevalent in women aged 30-50 years and there may be a genetic predisposition. They are more common in black women than white women. Other risk factors include obesity and nulliparity. Asymptomatic women should only be referred if their uterus is palpable abdominally, if fibroids distort the uterine cavity or the uterus is larger than 12 cm in length.

Managing debilitating menopausal symptoms

21 Mar 2016Paid-up subscribers

Severity and duration of menopausal symptoms varies markedly. Eight out of ten women experience symptoms and on average these last four years, with one in ten women experiencing symptoms for up to 12 years. Menopausal symptoms can begin years before menstruation ceases. A recent study found that women whose vasomotor symptoms started before the menopause suffered longest, median 11.8 years. Women whose hot flushes and night sweats started after the menopause had symptoms for a median of 3.4 years.

 

Editorials

Patients at increased suicide risk following cancer diagnosis

22 Feb 2019

Cancer patients are at increased risk of suicide, particularly in the first six months after diagnosis, a national population-based study in England has found. Compared with the general population, cancer patients had a 20% increased risk of suicide; standardised mortality rate (SMR) 1.20. The risk of suicide was highest during the first six months after diagnosis, SMR 2.74 (95% CI: 2.52-2.98), but remained raised for three years.

 

Clinical reviews of research - by GPs with interest

Reminder app improves compliance with CHD therapy

22 Feb 2019Registered users

The use of a widely available basic medication reminder app significantly improved adherence to treatment for coronary heart disease (CHD), in a study from Australia.

Afternoon exercise more beneficial for blood glucose than morning exercise in type 2 diabetes

22 Feb 2019Registered users

A small but well designed pilot study from Scandinavia has suggested that afternoon exercise improves blood glucose in type 2 diabetes more effectively than exercise in the morning.

Deaths associated with opioid overdose increase

22 Feb 2019

A study from Ontario, Canada, has found that prescribed, diverted and illicit opioids all play an important role in the recent increase in opioid-related deaths.

Rise in vaping accompanied by fall in youth smoking

22 Feb 2019

An increase in the use of e-cigarettes (vaping) has been associated with a drop in smoking by teenagers and young adults, a time trend analysis from the United States has found.

 

HASLAM's view

Should we warn patients about painful procedures?

22 Feb 2019

Having now experienced a depressingly wide selection of medical and surgical procedures, I feel more than a little embarrassed looking back that I didn’t truly appreciate exactly what my own patients were going through. Now this poses a really tricky problem. If I had known how unpleasant a treatment was, would that have made me more likely to dissuade my patients from giving their consent to having it done – albeit subconsciously or in the way I phrased my discussion?

 

A hundred years ago

100 years ago: Dreams and their value in treatment

22 Feb 2019Registered users

THE TREATMENT OF WAR PSYCHONEUROSES by making the sufferer face his memories and grow accustomed to them is directly opposed to the old-fashioned plan of urging him to “forget all about it.” The men have almost invariably been trying to forget, and need lengthy argument before they are convinced that the opposite process will help them, but an intelligent patient who has been through the “cure” is often able to overcome their objections, and help them to recall memories with the result that the emotional effect of these disappears as the patients grow more familiar with them. There are degrees of “forgetting,” from a mere reluctance to think of terrifying episodes up to a complete amnesia, even for the whole of a man’s experience in France.

 

A hundred and fifty years ago

150 years ago: A plea for compulsory vaccination in Scotland

22 Feb 2019Registered users

The greater number of recipients did not come under the notice of the regular practitioner at all, but were dealt with by the midwife, a canny friend, or the father, or mother, armed with clasp-knife or darning needle. I remember one amateur vaccinator of great local repute, a “surgeon to old shoes,” the weapon of whose anti-varioloid warfare was his awl. Matter belonging to any stage of vaccinia, or even the scrapings from the moistened under-surface of the effete crust, after it had dropped off from the arm, served the purpose; and when the produce of this rude husbandry was a pimple or sore of any description, it sufficed. In not a few cases, protection from small-pox was never involved in any way.