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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

Be vigilant for non-alcoholic fatty liver disease in primary care

28 Jul 2017Registered users

Non-alcoholic fatty liver disease (NAFLD) is now the most common cause of chronic liver disease in the Western world. Between 10 and 30% of NAFLD patients will develop non-alcoholic steatohepatitis (NASH) with a risk of progression to cirrhosis. Of those with NASH and fibrosis at presentation, studies have suggested that approximately 21% of patients will have some regression of fibrosis while 38% of patients will progress over five years’ follow-up.

Chronic pancreatitis may be overlooked and undertreated

28 Jul 2017Registered users

The prevalence of chronic pancreatitis is variable, with estimates between 4 and 52.4 per 100,000. A mismatch exists between reported incidence and prevalence in many studies suggesting chronic pancreatitis is under recognised. One cause for this mismatch is that once diagnosed many patients are lost to secondary care follow-up. Therefore, although a GP may only see two new cases during their career they are likely to encounter patients requiring recurrent consultations.

 

Special reports

Timely diagnosis of heart failure can improve prognosis

28 Jul 2017Paid-up subscribers

Heart failure is a common, complex clinical syndrome resulting from the impaired ability of the heart to cope with the metabolic needs of the body, leading to breathlessness, fatigue and fluid retention. It is a progressive disease characterised by high levels of morbidity and mortality. Keeping up to date with the 2016 European Society of Cardiology heart failure guidelines is important as a timely and accurate diagnosis of heart failure can significantly improve prognosis and symptoms, ensuring patients receive holistic patient-centred care from initial presentation to end of life.

Aerobic exercise can improve sleep and pain in fibromyalgia

22 Jun 2017Registered users

Fibromyalgia is a chronic condition characterised by regional pain at multiple sites, non-restorative sleep and fatigue. In the UK, it is a common cause of musculoskeletal pain and significant disability, affecting around 2% of the population. It has a female preponderance with a female to male ratio of 7:1. Self-help strategies are important. There is strong evidence of benefit from a slow graded increase in daily aerobic exercise which can increase delta sleep and restore descending pain inhibition mechanisms. Sleep hygiene should also be considered to promote delta sleep.

 

Clinical reviews of research - by GPs with interest

Risk of suicide in university students double that of graduates

22 Jun 2017Registered users

Compared with those who have completed university education, university students are more than twice as likely to commit suicide, a Swedish study has found.

Termination of pregnancy via telemedicine service safe and effective

22 Jun 2017Registered users

Women using an online telemedicine service for medical termination of pregnancy (MTOP) reported good outcomes, a study has found.Women using an online telemedicine service for MTOP reported good outcomes, a study has found. The study authors analysed data on all women from the Republic of Ireland and Northern Ireland who contacted the Women on Web telemedicine helpdesk, between January 2010 and December 2012. (In both countries termination is not available through the formal healthcare system except in restricted circumstances).

 

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: [email protected]

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.

Ulnar nerve injury on removal of a contraceptive implant

15 Dec 2016Registered users

The close proximity of contraceptive implant placement to the course of the ulnar nerve can result in injury. Several factors have been implicated in this complication including: low BMI, erroneous placement of the implant, implantation over the brachial groove, and migration of the implant from its original insertion. Clinicians should familiarise themselves with the vulnerable neurovascular structures in the area and refer promptly to a specialist if any neurological symptoms develop during placement or removal of these devices.

 

A hundred years ago

Dreams 3: Dreams and crime

22 Jun 2017Paid-up subscribers

WHAT IS THE ASSOCIATION of dreams with crime? I have questioned insane criminals about their dreams in connection with specific crimes, and although there is always some reserve about admitting revelations in connection with criminal acts, I find that they dream much as do other people. In this class, there is a considerable difficulty in proving their hidden personal secrets, and in overcoming the resistance of the so-called “censor”.

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.

 

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

 

Editorials

PPIs with aspirin in older patients lowers risk of major bleeds

28 Jul 2017Registered users

The current recommendation for patients suffering ischaemic vascular events is for lifelong antiplatelet treatment based on trial data mainly in patients under the age of 75. A UK prospective population-based cohort study assessed the risk, time course, and outcomes of bleeding on antiplatelet treatment for the secondary prevention of cardiovascular disease in patients of all ages. The Oxford Vascular Study (OXVASC) covers 92,728 patients registered with 100 GPs from nine practices in Oxfordshire.

 

Temporary access

Preventing stroke and assessing risk in women

22 Mar 2017

Ischaemic stroke is rare in premenopausal women but risk increases with advancing age and doubles in the ten years following the menopause. Up to the age of 75 years men have a 25% higher risk of suffering a stroke compared with women. However, the increased life expectancy of women ultimately results in a higher overall incidence. Twice as many women die from stroke compared with breast cancer. Women with cerebrovascular disease are more likely to present with atypical symptoms than men. Atrial fibrillation and hypertension, although less common than in men, are more potent risk factors for stroke in women.

Early recognition vital in acute coronary syndrome

24 Oct 2016

Acute coronary syndrome (ACS) includes both ST (STEMI) and non ST elevation (NSTEMI) MI, and unstable angina. Patients with ACS typically present with chest pain; classically central chest pain that radiates to the left arm. Additional symptoms include dyspnoea, nausea, sweating and syncope. However, patients can present atypically with gastric symptoms. These are often more common in patients with diabetes, women and the elderly. A 12-lead ECG should be performed if possible within 10 minutes of presentation or ideally at first contact with the emergency services.

 

HASLAM's view

Do surgeons or GPs take the greatest risks?

22 Jun 2017Registered users

Ask ten thousand people which they think is the riskiest – surgery or general practice – and the only ones who will answer general practice will be surgeons or GPs. To the vast majority of the population, the drama of surgery looks horrifically risky. The drama of general practice may not be as great as it is for those who skilfully wield a scalpel while working medical and surgical miracles. However, a life that is saved by early diagnosis is just as much a life as one that is rescued from a life-threatening event.

 

CPD exercises associated with each issue

CPD exercise - June 2017

22 Jun 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 heart disease in children and adolescents • Early referral key to better outcomes in eating disorders • Aerobic exercise can improve sleep and pain in fibromyalgia

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