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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

Improving the recognition of autism in children and adults

22 May 2018Registered users

Autism covers a wide spectrum across the dimensions of social communication, repetitive and stereotyped behaviours as well as other non-clinical and cognitive features. Individuals with autism can function well in certain environments, where there are fewer demands to multitask and factual information and pattern recognition are required, but they may not function well in highly social environments, or situations characterised by rapid and unpredictable change.

Managing patients with severe mental illness and substance misuse

22 May 2018Registered users

Co-occurring severe mental illness, usually schizophrenia or bipolar affective disorder, and substance misuse is termed dual diagnosis. Mental illness and its consequences may lead to substance misuse as a coping strategy. Substance misuse can lead to mental health problems, either by triggering a first episode in a susceptible person, or by exacerbating an existing disorder. However, substance misuse itself is unlikely to be the sole cause of a severe and enduring mental illness.

 

Special reports

Diagnosis and management of migraine in primary care

22 May 2018Registered users

Migraine is common, with a global prevalence of 14.7% and a lifetime prevalence in the UK of 20-25%. A UK study found that there were 4.44 consultations for headache per 100 registered patients aged = 15 years per annum. The Landmark study, from 15 countries, reported that 94% of patients attending a GP with episodic disabling headache had migraine.

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.

 

Clinical reviews of research - by GPs with interest

Smoking duration the best indicator of COPD progression

22 May 2018Registered users

The number of years that an individual has been smoking is closely linked to the degree of structural lung disease, airflow obstruction and functional outcomes in chronic obstructive pulmonary disease (COPD). It is a better measure than pack-years or the number of cigarettes smoked per day, a large study from the USA has shown.

Patients with heart failure not being diagnosed in primary care

22 May 2018Paid-up subscribers

Only a quarter of patients with symptoms suggestive of heart failure are investigated and referred by GPs in accordance with NICE guidelines, a UK study has shown. Nearly 80% of heart failure patients were diagnosed in hospital. The investigators, from Imperial College, London, extracted data on patients diagnosed with heart failure between 1 January 2010 and 31 March 2013, using the Clinical Practice Research Datalink. This database contains electronic records from 7% of general practices in England.

C-peptide testing can identify risk of hypoglycaemia in insulin-treated type 2 diabetes

22 May 2018Paid-up subscribers

Low levels of C-peptide were associated with greater glucose variability and hypoglycaemia in type 2 diabetes patients on insulin,a UK study has found.

Composition of vaginal microbiota may increase risk of chlamydia infection

22 May 2018Paid-up subscribers

 Lactobacillus iners-dominated vaginal microbiota was associated with increased susceptibility to Chlamydia trachomatis infection in women, in a Dutch nested case-control study.

 

CPD exercises associated with each issue

CPD exercise - May 2018

22 May 2018Paid-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: • Improving the recognition of autism in children and adults • Managing patients with severe mental illness and substance misuse • Diagnosis and management of migraine in primary care

 

Diabetes

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.

Frailty predicts adverse outcomes in older people with diabetes

23 Jan 2017Paid-up subscribers

In older people living with diabetes, geriatric syndromes, which indicate frailty, are emerging as a third category of complications in addition to the traditional microvascular and macrovascular sequelae. Frailty is defined by the presence of three or more phenotypes (weight loss, weakness, decreased physical activity, exhaustion and slow gait speed). Patients may progress from a non-frail to pre-frail or frail state. With timely intervention, there is a greater chance for an individual to recover from pre-frail to non-frail than to deteriorate into frailty.

 

Editorials

How effective are antidepressants?

22 May 2018Registered users

All antidepressants are more efficacious than placebo in adults with major depressive disorder, a systematic review and meta-analysis has found. Double-blind, randomised controlled trials were identified from the Cochrane Central Register of Controlled Trials and other large databases. Placebo-controlled and head-to-head trials of 21 antidepressants (a selection of first-generation and all approved second-generation antidepressants) were included.

 

HASLAM's view

How often do patients cry in your consulting room?

04 Jun 2018Registered users

So many people used to cry in my consulting room that I had to buy tissues in bulk. I used to wonder what my remarkable experience of crying patients was triggered by. I eventually concluded that the main factor was safety. People should feel safe when they are in with their doctor. I think our patients should feel free to let their feelings out in the consulting room.

 

Letters

 

Photoguide selection - with PubMed links

Sun damage

23 Jun 2016Registered users

 • Squamous cell carcinoma • Actinic keratosis horn • Bowen’s disease • Solar elastosis • Rosacea • Discoid lupus

Allergic reactions

24 Sep 2015

• Fixed drug eruption • Fabric plaster reaction • Latex allergy • Morbilliform drug reaction • Allergic conjunctivitis • Anaphylaxis

Urgent referrals

23 Mar 2011

• Eczema herpeticum • Pemphigus vulgaris • Perinephric abscess • Quinsy [with pre-set links to the evidence base]

 

A hundred years ago

Enuresis in childhood

23 Apr 2018Registered users

It is easy to see the ill-effects of circumstances which add new force to the fear of failure or shake the confidence in the control which has been regained.  Thus, a boy, an only child, who had suffered from enuresis till his seventh year, had regained complete control till his eleventh year, when he went to school. In his dormitory at school was a boy who had enuresis, and was being fined and punished by the schoolmaster. The enuresis at once reappeared and continued unchecked while he was at school.

 

A hundred and fifty years ago

Blood-letting in eye disorders

22 May 2018Registered users

From inquiries made at several of the large dispensing houses in Liverpool, I find that the demand for leeches has dwindled down to a mere tithe of what it was ten years ago. At most of the hospitals and dispensaries they are so rarely required, that they are not kept in stock at all, but sent for when ordered. As for cupping and bleeding from the arm, they are never heard of now. The following cases show the mistake which will be made if  blood-letting is altogether lost sight of or omitted from our therapeutics.