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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

Optimising the management of systemic lupus erythematosus

22 May 2019Paid-up subscribers

Systemic lupus erythematosus (SLE) is a multisystem, autoimmune disease. SLE mainly affects women and causes fatigue, rashes (often associated with photosensitivity), hair loss and inflammatory arthritis. However, it can also affect men in whom it is often more severe with a greater likelihood of renal involvement and a greater degree of organ damage. According to the British Society for Rheumatology guideline, the diagnosis of SLE requires a combination of clinical features and the presence of at least one relevant immunological abnormality.

Education the key to improving outcomes in gout

22 May 2019Registered users

The most common presentation of gout is a flare, characterised by acute onset of one, or occasionally more, hot, red, swollen joints which are very painful and tender. Less common is insidious onset of chronic usage related joint pain, especially in joints already affected by osteoarthritis. Subcutaneous tophi can also be the presentation, particulary in older people. In typical cases, clinical assessment alone is sufficient for diagnosis. Gout is also associated with comorbidities such as nephrolithiasis, chronic kidney disease, metabolic syndrome and heart disease, and increased mortality.

 

Special reports

Managing urinary incontinence in women

22 May 2019Paid-up subscribers

A detailed patient history is key to the assessment of patients with urinary incontinence and to guiding initial investigation and management. Clinical examination should include abdominal palpation to assess for masses, including an enlarged bladder. Visual inspection of the perineum and vagina helps determine whether the patient may be hypo-oestrogenic and can confirm the presence and grading of pelvic organ prolapse. Digital vaginal examination enables detection of masses, and an assessment of pelvic floor muscle strength. Urinalysis should also be carried out. Most patients will have either stress, urgency, or mixed urinary incontinence.

 

COPD

Optimising the management of patients with COPD

25 Mar 2019Registered users

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.

Pulmonary rehabilitation improves exercise capacity and quality of life

23 Jan 2018Registered users

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.

Improving outcomes in COPD

23 Nov 2017Registered users

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.

 

CPD exercises associated with each issue

CPD exercise - May 2019

22 May 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: • Education the key to improving outcomes in gout • Optimising the management of systemic lupus erythematosus • Managing urinary incontinence in women

 

Cardiovascular disease

Managing arrhythmias in coronary artery disease

23 Jan 2019Registered users

A detailed history is essential in patients with coronary artery disease (CAD) to elucidate red flag symptoms necessitating urgent specialist assessment. Red flags include syncope and presyncope, particularly in patients with concomitant left ventricular systolic dysfunction. Palpitations with severe chest pain and breathlessness also warrant urgent assessment. Undiagnosed atrial fibrillation (AF) is common in older populations. LVEF of 35% or less is a predictor of increased risk of sudden death. All patients with CAD should therefore undergo assessment of LVEF, usually by transthoracic echocardiography.

Managing stable angina in primary care

22 Oct 2018Paid-up subscribers

Around 50% of people diagnosed with ischaemic heart disease present with stable angina as the first symptom. The likelihood of a diagnosis of angina increases with the number of cardiovascular risk factors present. A resting 12-lead ECG is recommended for all patients with suspected angina. However, a normal result does not exclude the presence of underlying coronary artery disease.

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).

 

Editorials

HRT may increase the risk of Alzheimer’s disease

22 May 2019Registered users

Postmenopausal women who take systemic hormone replacement therapy (HRT) are more likely to develop Alzheimer’s disease, although the increase in risk is modest, a Finnish nationwide case-control study has found.

 

HASLAM's view

You can’t tell a book by its cover

22 May 2019Registered users

There are now about 350 different roles in the NHS, according to the recruitment website stepintothenhs.nhs.uk. As your practice expands, or merges, or integrates, the challenge for our patients of understanding who precisely is who is likely to get worse and worse.

 

Research reviews - by GPs with a special interest

Do 5 alpha-reductase inhibitors raise the risk of type 2 diabetes?

22 May 2019Paid-up subscribers

Finasteride and dutasteride appear to be associated with a modest increase in the risk of developing type 2 diabetes, according to the findings of a retrospective cohort study.

Does paternal age affect perinatal outcomes?

22 May 2019Paid-up subscribers

A retrospective population based cohort study from the United States has found a modest correlation between older paternal age and adverse perinatal outcomes.

Sitting time linked to raised mortality risk in inactive adults

22 May 2019Paid-up subscribers

Sitting for long periods is associated with an increased risk of all cause and cardiovascular disease (CVD) mortality among the least physically active adults. However, moderate to vigorous physical activity equivalent to public health recommendations can attenuate or effectively eliminate such associations, a study from Australia has found.

Adolescents face barriers to accessing sexual health information online

22 May 2019Paid-up subscribers

Teenagers are reticent to search for sexual health information online, a small qualitative study has found.

 

A hundred and fifty years ago

150 years ago: The use and abuse of alcohol by young women

22 May 2019Registered users

MANY GIRLS WHO LIVE AMONG RICH (especially nouveau riche) and gay society are in the habit, during six months out of the twelve, of taking a daily average of  2, 2½ or 3 ounces of absolute alcohol, a quantity which, if expressed in cheap beer, would be equal to six or seven pints.

 

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.