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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

Managing acute asthma in children

25 Jun 2018Registered users

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. 

Be vigilant for depression in children and adolescents

25 Jun 2018Registered users

The symptoms of depression in adolescents are similar to those in adults. Depression in children of primary school age may be very subtle and symptoms include mood fluctuations, tearfulness, frustration or temper tantrums. If depression is suspected, it is essential to evaluate the degree of risk. Risk has two key aspects: the likelihood of a potentially harmful incident occurring and degree of potential harm.

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.

Identifying and managing men with early prostate cancer

23 Apr 2018Paid-up subscribers

Prostate cancer is the most common cancer in men in the UK. Men have a 1 in 8 lifetime risk of being diagnosed with the disease. Factors associated with an increased risk of prostate cancer include: age > 50 years, black ethnicity, a first-degree relative with prostate cancer, and obesity. Patients may present with erectile dysfunction or lower urinary tract symptoms such as frequency, hesitancy, nocturia, or haematuria.

 

Clinical reviews of research - by GPs with interest

Earlier onset of type 2 diabetes increases mortality risk

25 Jun 2018Registered users

Onset of type 2 diabetes at a younger age is associated with increased mortality, mainly from earlier death from cardiovascular disease (CVD), a study from Australia has found.

Active surveillance vs immediate treatment for CIN2

25 Jun 2018Registered users

Active surveillance may be a suitable option in selected, particularly younger, women with CIN2, a systematic review and meta-analysis has concluded.

 

CPD exercises associated with each issue

CPD exercise June 2018

25 Jun 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:• Managing acute asthma in children • Be vigilant for depression in children and adolescents • Tailor BP targets to the older patient with hypertension

 

Special reports

Tailor BP targets to the older patient with hypertension

25 Jun 2018Registered users

Prevalence of hypertension increases with age and older people are likely to benefit more from BP reduction because of their high baseline cardiovascular risk. However, older people are a very heterogeneous group and a single BP target will not be appropriate for all. Current evidence is based on ambulatory or healthy older populations as patients with significant complex conditions were not represented in randomised clinical trials. 

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.

Pruritus may be a symptom of underlying systemic disease

22 Mar 2018Paid-up subscribers

Itch is a common symptom of many dermatological conditions (e.g. eczema, urticaria and lichen planus) but can also be a manifestation of underlying systemic, neurological and psychological disorders, or an adverse reaction to medication. The assessment of patients with generalised itch but no rash requires a detailed history and examination to narrow the spectrum of potential causes. Examination should include inspection of the entire skin. Physical examination should include palpation for lymphadenopathy and organomegaly.

Diagnosis and management of oesophageal cancer

22 Feb 2018Registered users

Oesophageal cancer commonly presents with dysphagia or odynophagia and can be associated with weight loss and vomiting. Referral for urgent endoscopy should always be considered in the presence of dysphagia regardless of previous history or medication. NICE recommends urgent referral (within 2 weeks) for direct access for upper GI endoscopy in patients with dysphagia and those aged 55 years or over with weight loss and any of the following: upper abdominal pain, reflux, or dyspepsia.

 

Editorials

GP auscultation a poor predictor of valvular heart disease

25 Jun 2018Registered users

Auscultation has only limited accuracy in the detection of valve disease in asymptomatic patients and is a poor diagnostic screening tool in primary care, a UK study has found.

 

HASLAM's view

Are you a bully?

25 Jun 2018Registered users

I’m sorry if the question offends you, but I suspect it is one we all need to ask.  After all, the chances are you will have no idea if you are a bully or not. Most bullies in medicine and healthcare are blissfully unaware of the fact. But it’s a real issue.

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.

 

Photoguide selection - with PubMed links

Sun damage

23 Jun 2016

 • 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 and fifty years ago

150 years ago: Pancreatic emulsion in the wasting diseases of children

25 Jun 2018Registered users

Pancreatic emulsion is  now widely used in the wasting diseases of adults, but is not even referred to in the latest works on the diseases of children. Yet scarcely a week now passes but some general practitioner relates to me cases of the successful use in his own practice of pancreatic emulsion in the wasting of delicate children; showing that in this respect the rank and file of our professional army are in advance of some of their generals.

 

A hundred years ago

100 years ago: The tuberculosis problem: Prevention

25 Jun 2018Registered users

The preventive treatment is carried out by medical officers of health, sanitary inspectors, nurses and health visitors, who visit the homes of notified cases, investigate home conditions and give advice in a more or less conventional way.But it often happens that a child has been notified, or a young adult, when the chief source of infection is one of the patient’s grandparents, a relative staying in the house...A notified tuberculous father may be given a room to himself, while his wife, who has chronic tuberculosis and is the source of his infection, is sent to sleep with, and infect, the children.  Or a child with enlarged glands is removed from the company of other children, some of whom have glands equally large (but unnoticed), and sent to sleep with the tuberculous grandmother.