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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

Investigating the cause of heavy menstrual bleeding

25 Mar 2019Registered users

Heavy menstrual bleeding has been defined as ‘excessive menstrual blood loss which interferes with a woman’s physical, social, emotional, and/or material quality of life’. Heavy menstrual bleeding affects 25% of women of reproductive age and is estimated to be the fourth most common reason for gynaecological referrals. Women should be asked about pelvic pain which might suggest endometriosis and pressure symptoms which might suggest significant fibroids. Examination is appropriate if there is intermenstrual or postcoital bleeding and, if the woman is actively bleeding, may identify the source of the bleeding.

Diagnosis and management of premenstrual syndrome

25 Mar 2019Registered users

The term premenstrual syndrome (PMS) refers to a constellation of mood and physical symptoms that occur during the luteal phase of the menstrual cycle. The National Association for Premenstrual Syndrome suggests that: ‘If PMS symptoms affect personal and/or social and/or professional quality of life then this should be regarded as being clinically significant PMS.’ Some women give a clear history of onset during the luteal phase of the menstrual cycle, with improvement taking place within a few days after the onset of menses. However, other women present with fluctuating symptoms without making a connection with their menstrual cycle. There are no diagnostic tests for PMS; diagnosis is dependent on the history. 

 

Special reports

Optimising the management of patients with COPD

25 Mar 2019

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.

Optimising outcomes in chronic heart failure

22 Feb 2019

Although patients can present with non-specific symptoms and minimal clinical signs, generally, in the community, patients with heart failure present with symptoms of dyspnoea or fluid retention. In order to confirm (or refute) the diagnosis, NICE recommends natriuretic peptide testing (ideally N-terminal pro B-type natriuretic peptide; NT-proBNP) in all patients with suspected heart failure. An NT-proBNP level > 2,000 ng/L is highly suggestive of heart failure and NICE recommends echocardiography and specialist review within 2 weeks. Conversely, an NT-proBNP level < 400 ng/L suggests that a diagnosis of heart failure is unlikely. Patients with an NT-proBNP of 400-2,000 ng/L should have echocardiography and specialist assessment within 6 weeks.

 

CPD exercises associated with each issue

CPD exercise - March 2019

25 Mar 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: • Investigating the cause of heavy menstrual bleeding • Diagnosis and management of premenstrual syndrome • Optimising the management of patients with COPD

 

Psychiatry

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 2018

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.

Be vigilant for dementia in Parkinson’s disease

23 May 2017

It is estimated that up to 80% of patients with Parkinson’s disease will eventually develop cognitive impairment over the course of their illness. Even at the time of diagnosis, cognitive impairment has been reported in 20-25% of patients. Commonly affected domains are executive function, visuospatial ability and attention control. In addition, patients with Parkinson’s disease dementia may present with deficits in language function and verbal memory.

Diagnosing and managing mild cognitive impairment

23 May 2017Paid-up subscribers

The prevalence of mild cognitive impairment in adults aged 65 and over is estimated to be 10-20%. It is likely that this figure will increase in line with trends in dementia diagnosis. In some cases, mild cognitive impairment may be a prodrome for dementia, and may be caused by any of the dementia pathology subtypes. It is important to obtain a history of cognitive changes over time, as well as information about the onset and nature of cognitive symptoms, confirmed by a reliable informant, if available.

 

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.

Management and prevention of renal and ureteric stones

22 Feb 2019Registered users

Kidney stones are common with as many as 1 in 10 people developing a symptomatic stone. Up to 50% of stone formers will have at least one further symptomatic stone in their lifetime. Ureteric colic is unaffected by posture with patients often writhing in seemingly futile attempts to relieve pain. Immediate management comprises effective analgesia while urinalysis is the first step in confirming the diagnosis. One of the challenges facing the GP is to differentiate patients who warrant immediate hospital referral from those who can be seen less acutely.

Improving outcomes for kidney transplantation

20 Dec 2018Registered users

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).

 

Paediatrics

GPs play a vital role in identifying and managing juvenile idiopathic arthritis

24 Sep 2018Registered users

Juvenile idiopathic arthritis (JIA) affects approximately 1-4 per 1,000 children under the age of 16. Girls are more commonly affected than boys. It is a heterogeneous condition, even within JIA categories, ranging from insidious arthritis affecting one to two joints to florid and life-threatening systemic arthritis. All patients with suspected JIA should be referred urgently to a specialist paediatric rheumatology team. Coordinated, multidisciplinary care within a specialist team is required to achieve optimal outcomes.

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 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.

 

Editorials

Diabetes triples risk for occlusive vascular events in women

25 Mar 2019Registered users

Diabetes is known to increase the risk of occlusive vascular events, and this is one of the main causes of premature death associated with the condition. A recent meta-analysis of nearly one million individuals has shown that the risk of occlusive events in diabetes is doubled for men but tripled for women. Importantly, this study was able to control for other major vascular risk factors.

 

HASLAM's view

The doctor’s dilemma

25 Mar 2019Registered users

Every now and then in my career as a GP I found myself completely unable to know what to say. Part of every GP’s job is that vital skill of knowing what to do when you don’t know what to do, but on occasions I found this skill was distinctly lacking. I’m sure I’m not the only one. One of the most astonishing things about general practice is how you keep finding yourself in situations where you’ve never been before. On this occasion I really felt that I was floundering.

 

Clinical reviews of research - by GPs with interest

Alcohol use disorder affects offspring’s behaviour in adulthood

25 Mar 2019Registered users

Parental alcohol use disorder is associated with an increased likelihood of marriage to a spouse with alcohol use disorder, a Swedish population-based study has found. In particular, daughters of affected mothers were more likely to have an affected spouse.

Does intensive BP lowering reduce risk of dementia?

25 Mar 2019Registered users

Intensive blood pressure (BP) control reduces the risk of developing mild cognitive impairment, but not dementia, a US randomised trial has found.

Are e-cigarettes more effective than nicotine replacement therapy to help smokers quit?

25 Mar 2019Registered users

One year smoking cessation rates were significantly higher in those who used e-cigarettes compared with those using traditional nicotine replacement therapy (NRT) products, in a UK prospective study. However, many more of those on e-cigarettes who had quit ordinary cigarettes still used the substitute while most of those who quit using NRT were free from treatment.

Cuffless vs standard devices for ambulatory blood pressure monitoring

25 Mar 2019Registered users

A novel cuffless device recorded significantly higher values for both systolic and diastolic blood pressure (BP) compared with standard equipment for 24-hour ambulatory BP monitoring, in a small study from Switzerland.

 

A hundred and fifty years ago

150 years ago: Stimulant-narcotics in elderly persons

02 Apr 2019Registered users

THE LONG LEGAL CAREER of Sir Frederick Pollock was combined especially with a large amount of  scientific reading.  Favoured with an almost unbroken health, Sir F Pollock FRS has reached the great age of 86, yet still retains his mental energy and activity; while as regards physical status, with the exception of the inevitable decline of muscular energy, he at present scarcely betrays his age in any noticeable manner. About six years ago, however, he was led to adopt ether-inhalation by the occurrence of symptoms which were annoying, and had a chronic depressing tendency. Besides a certain  indefinable nervous malaise, he suffered specifically from gastric flatulence and painful spasm, occurring almost constantly during meals.

 

A hundred years ago

100 years ago: Prevention of venereal disease

25 Mar 2019Registered users

IF ONE REVIEWS THE LITERATURE ON prevention of venereal disease, one finds much on the inspection and segregation of prostitutes, but comparatively little on measures which are applicable to men. Yet I am sure that it should be very much the other way about.