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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

Pulmonary rehabilitation improves exercise capacity and quality of life

23 Jan 2018

Pulmonary rehabilitation is a multifaceted programme of exercise and education that aims to improve breathlessness, exercise capacity, and quality of life, and aid self-management.  Patients with chronic respiratory failure, those on long-term or ambulatory oxygen and patients with anxiety and depression can all benefit from rehabilitation. It is one of the most beneficial and cost-effective treatments for COPD and should be considered a fundamental component of disease management rather than an option.

Timely diagnosis of vascular dementia key to management

23 Jan 2018Registered users

Vascular dementia is the second most common type of dementia, after Alzheimer’s disease, and accounts for 15% of cases. The core diagnostic features include cognitive impairment in at least two domains (orientation, attention, language, visuospatial function, executive function, motor control and praxis), which affect social or occupational function, together with evidence of cerebrovascular disease (focal neurological signs or neuroimaging). Crucially there should be a temporal relationship between cerebrovascular disease and the onset of cognitive changes.

Prompt diagnosis can prevent joint damage in psoriatic arthritis

20 Dec 2017Registered users

Psoriatic arthritis (PsA) is a chronic, autoimmune inflammatory condition that can affect up to 30% of patients with psoriasis. It is part of the seronegative spondyloarthropathy group of rheumatic diseases which also includes reactive arthritis and ankylosing spondylitis. It can be a multisystem disease affecting the eyes, the gut and the tendons and is associated with comorbidities such as ischaemic heart disease and metabolic syndrome. Early diagnosis is key as structural joint damage can occur within two years of disease onset. 

Early recognition pivotal in the management of spondyloarthritis

20 Dec 2017Registered users

The spondyloarthritis group is divided into two main subgroups: axial spondyloarthritis and peripheral spondyloarthritis. These may exist as separate entities or coexist in the same patient. Classically, axial spondyloarthritis presents with insidious onset inflammatory lower back pain, which is typically worse in the morning and after rest, and improves with activity. Peripheral spondyloarthritis can present with peripheral joint pain and/or swelling, swelling of the digits (dactylitis), tendon and entheseal pain that is not secondary to a mechanical cause. Early referral of patients with suspected spondyloarthritis to specialist care is strongly recommended as this can improve long-term outcomes.

Improving outcomes in COPD

23 Nov 2017

Cigarette smoking is overwhelmingly the most important risk factor for COPD. In some cases, other factors such as occupation, passive exposure to inhalants and fetal nutrition/low birthweight are also important. The diagnosis should be suspected in symptomatic patients with risk factors, usually cigarette smoking, aged 40 years or above, albeit a majority of people with COPD present when considerably older. The 2017 GOLD guideline recommends that management should be focused on two objectives. First, to relieve symptoms of breathlessness (assessed using the MRC dyspnoea scale) and improve quality of life (assessed by the COPD Assessment Test). Second, to reduce risk assessed by the number of exacerbations and hospitalisations in the previous year.

Regular review pivotal in chronic asthma in children

23 Nov 2017Registered users

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.

 

Special reports

Diagnosing and managing sepsis in children

23 Jan 2018Registered users

The clinical features of sepsis are: fever; tachycardia, with no other explanation; tachypnoea, with no other explanation; leukocytosis or leucopenia. To meet the International Pediatric Sepsis Consensus Conference definition, a patient should have two of these features, one of which should be fever or abnormal white cell count, in the presence of infection. Every time a child who has symptoms or signs suggestive of infection is assessed, it is important to consider whether this could be sepsis. This may seem obvious in a child presenting with fever, but not all children with sepsis present with high fever or focal signs.

 

Clinical reviews of research - by GPs with interest

Breathing self-management programme improves quality of life in asthma

23 Jan 2018

A breathing retraining exercise programme, incorporating a training DVD and accompanying booklet, achieved similar improvements in quality of life scores as conventional face to face training in patients with asthma, in a UK study.

Self-taken swabs can detect bacterial vaginosis and candidiasis

23 Jan 2018Registered users

Lower vaginal swabs taken by patients are as reliable as high vaginal swabs taken by clinicians for the detection of vulvovaginal candidiasis or bacterial vaginosis, a UK study has shown.

Triple antiplatelet therapy no better than standard regimens after ischaemic stroke

23 Jan 2018Registered users

Intensive antiplatelet therapy with three agents did not reduce the incidence and severity of recurrent stroke or transient ischaemic attack (TIA) but did significantly increase the risk of major bleeding in the TARDIS study.

Benzodiazepines and Z-drugs are being widely used long term

23 Jan 2018Registered users

A UK primary care survey has found that many patients are taking benzodiazepines or Z-drugs, recommended for short-term use, for at least a year.

 

A hundred years ago

Anorexia nervosa in children

23 Jan 2018Registered users

Above all, we must hide from the child that we care at all if he eats too little. The nurse, more often than the mother, is apt to persist in the policy of coaxing, urging and commanding. The nurse who urges a child to eat, like the nurse who leaves the room with the parting injunction to the children not to put beads up their noses, has much to learn in the management of children.

 

A hundred and fifty years ago

On the dangers of blistering

23 Jan 2018Registered users

The child was lying, with head bent, hanging by its own weight, so incapable was the wasted neck of sustaining it. But when I was going to take his arm to take the pulse, he sprang up like a lion, open-mouthed, to bite my hand. “What is that for?” I asked the mother. “Ah, sir,” said she, “he thought you were going to dress his blisters. He always does that when we go to dress them, and we are obliged to hold him.”

 

Editorials

Should sertraline be used in CKD patients with depression?

23 Jan 2018Registered users

Sertraline is ineffective in patients with chronic kidney disease (CKD) and depression, a randomised controlled trial, from the USA, has found. This study suggests that the prescription of sertraline, and indeed any SSRI, to stage 3b-5 CKD patients with depression can no longer be justified. CBT is probably the best option and there is some evidence of its efficacy in end-stage CKD patients.

 

HASLAM's view

Identifying specimens has never been my strong point

23 Jan 2018Registered users

‘I bet you’ve no idea what this is,’ he said. Thrusting his hand deep into his back pocket, my 74-year-old patient pulled out a small pebble-like object and held it up. What on earth was it? I had thought the consultation had come to an end. He was proffering me a curious organic object. Could it be a gallstone? I really wasn’t sure.

 

CPD exercises associated with each issue

CPD exercise - January 2018

23 Jan 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: • Timely diagnosis of vascular dementia key to management • Pulmonary rehabilitation improves exercise capacity and quality of life • Diagnosing and managing sepsis in children

 

Case reports

Palpitations: when you hear hoof beats don’t forget to think zebras

24 Apr 2017Registered users

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.

 

Temporary access

Skin conditions in children

25 Jan 2016

 • Classic spitz naevus •  Irritant saliva dermatitis •  Umbilical granuloma •  Cradle cap •  Molluscum contagiosum •  Juvenile plantar dermatosis