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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

Early recognition and treatment vital in acute prostatitis

24 Apr 2019Registered users

Acute prostatitis is an acute bacterial infection of the prostate gland, often associated with other urinary tract infections. Patients with acute prostatitis present feeling generally unwell with fever, rigors, pelvic pain and lower urinary tract symptoms. Acute prostatitis can also present with, or lead to, acute urinary retention. Patients who are systemically unwell should be referred urgently to secondary care for intravenous antibiotics and further investigation, as should those failing to respond appropriately or deteriorating on review after 48 hours. Chronic bacterial prostatitis is characterised by symptoms that last for more than three months. 

History key in identifying cause of nocturia in men

24 Apr 2019Registered users

Nocturia can be a symptom of an underlying disease process or behavioural. The history should not just focus on lower urinary tract symptoms but should also include past medical history, current medications and fluid intake. It is important to ask specifically about the onset and progression of symptoms, and to what extent the patient is troubled by the nocturia. An abdominal examination should always be performed and should exclude urinary retention. A digital rectal examination of the prostate should also be offered.

 

Special reports

Improving outcomes in obese pregnant women

24 Apr 2019Registered users

For obese women the risks of adverse outcomes during pregnancy, for both the mother and her child, are significantly higher than for the general population. In 2016, 21% of all women attending antenatal services in the UK were reported to have a BMI of 30 kg/m2 or higher. In 2003-2005, 27% of all maternal deaths occurred in women with a BMI of 30 kg/mor higher. Obesity increases the risk of venous thromboembolism, gestational diabetes, pre-eclampsia and hypertension. There is an increased likelihood of induction of labour, instrumental delivery and postpartum haemorrhage. The greatest effect on risk reduction is weight loss prior to conception.

Optimising the management of patients with COPD

25 Mar 2019Paid-up subscribers

COPD should be suspected in an older adult (at least 35 years old but typically more than 45 years old) who presents with symptoms such as breathlessness, wheeze, cough and sputum production and has one or more risk factors, typically current, or a past history of, cigarette smoking. A diagnosis should also be suspected when an individual with a risk factor develops a lower respiratory tract infection requiring treatment. COPD is far more common in smokers of heroin and crack cocaine, in whom it occurs at a younger age.

 

CPD exercises associated with each issue

CPD exercise - April 2019

24 Apr 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: • Early recognition and treatment vital in acute prostatitis • History key in identifying cause of nocturia in men • Improving outcomes in obese pregnant women

 

Paediatrics

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 childhood eczema can be challenging

25 Sep 2017Registered users

Atopic eczema is the most common endogenous type of eczema in infants and children and affects around 15-20% of school-age children in the UK. Its prevalence is highest in children under the age of two and subsequently diminishes with age. It has a chronic, relapsing course. An emergency referral to a dermatologist or paediatrician should be made via telephone when there is a suspicion of eczema herpeticum or eczema coxsackium. Other indications for referral include diagnostic uncertainty, recurrent secondary infection, when control remains poor despite topical treatments, and for patients with emotional distress or significant sleep disturbance.

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.

 

Dermatology

Improving detection of non-melanoma skin cancer

05 Aug 2015Registered users

Basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) are clinically and pathologically distinct and both are locally invasive. However, while BCCs rarely metastasise, SCCs have the potential to do so especially when they arise on the ears or lips. Patients with one non-melanoma skin cancer (NMSC) have a higher risk of developing another NMSC and of malignant melanoma.

GPs have key role in early detection of melanoma

24 Jun 2013Registered users

Lesions which have a high index of suspicion for melanoma should not be removed in primary care. Patients should be referred urgently to secondary care with a history recording the duration of the lesion, change in size, colour, shape and symptoms. 

 

Renal medicine

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.

Improving outcomes for kidney transplantation

20 Dec 2018Paid-up subscribers

Kidney transplantation is the optimum form of renal replacement therapy for suitable patients with end-stage renal disease. A successful transplant represents a much closer approximation to true renal replacement with excretion of waste products, regulation of electrolytes and other substances, than dialysis. The longer a recipient has been dialysis dependent before transplantation the poorer the outcome. Living donor transplantation is associated with better graft and patient survival than transplantation from a deceased donor. A genetic relationship with the recipient is not a prerequisite to becoming a living donor. Having a living donor offers the opportunity of pre-emptive transplant (i.e. avoidance of dialysis altogether).

 

Editorial

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Editorials

HPV vaccination significantly reduces cervical disease

24 Apr 2019Registered users

A landmark study from Scotland has shown that bivalent HPV vaccine confers significant protection against cervical epithelial dyskaryosis and dysplasia, both precursors of invasive cervical cancer. This study reports statistically significant reductions in all grades of CIN, equating to vaccine effectiveness estimates of 80% or greater after routine immunisation of girls at age 12-13 years.

 

HASLAM's view

Was I making a drama out of a crisis?

24 Apr 2019Registered users

I was doing morning surgery when the phone on my desk rang. My receptionists knew that I hated being disturbed, so I felt it must be urgent. It was. One of our local midwives was calling. She sounded breathless and rather panicked. A home delivery was not going well, and she needed my help.

 

Clinical reviews of research - by GPs with interest

Regular cannabis use raises risk of psychosis

24 Apr 2019Registered users

Daily cannabis use is associated with a three-fold increased risk of psychotic disorder, a multicentre, international case-control study has shown.

Continuous ECG vs loop recording for AF detection post stroke

24 Apr 2019Registered users

Automatic external loop recording (ELR) is not suitable as a single monitoring device for AF screening following stroke, a prospective cohort study from Denmark has concluded.

SGLT2 inhibitor produces good glycaemic control in everyday practice

24 Apr 2019Registered users

An observational study from Scotland has shown that dapagliflozin produced equivalent improvements in glycaemic control in patients with type 2 diabetes in general practice to those reported in clinical trials.

Educational intervention encourages smokers to consult with respiratory symptoms

24 Apr 2019Registered users

Although an educational intervention increased respiratory consultations in smokers it did not improve detection of lung cancer, in a randomised controlled trial from Australia.

 

A hundred and fifty years ago

150 years ago: Sur La Migraine by Dr Elizabeth Garrett

24 Apr 2019Registered users

IT WOULD BE IMPOSSIBLE, in any case, to pass without notice so striking an event as the appearance of the inaugural treatise of the first lady - an English lady, moreover - who has ever passed through the formidable ordeal of the examination for the Paris doctorate of medicine. It is not the province of this journal to discuss medical politics, and we shall not pronounce any opinion as to the probability of lady doctors, in any considerable numbers, acquiring such a genuine knowledge of medical science as is displayed in Dr Garrett’s inaugural treatise; but we may at least say that we should personally be delighted to welcome as colleagues any number of ladies who should prove themselves to have mastered their profession as she has done.

 

A hundred years ago

100 years ago: Poison-gas in war

24 Apr 2019Registered users

THE SHAME AND OBLOQUY of introducing poison-gas as a weapon in modern war must rest for ever with Germany, who, in spite of, or perhaps, because of, her signed agreements not to use gas, attacked the Allied line in the neighbourhood of Ypres on April 22 1915 in a chlorine gas cloud. Poison-gas, now one of the deadliest and most dreaded weapons of modern war, is not, as popularly held, an entirely new method of warfare. Poisonous fumes were used in warfare centuries before the rifle or shell were thought of.