The Practitioner

The Practitioner is a PubMed indexed general medical review monthy journal with subscribers throughout the world. The Practitioner and this website are also used by doctors preparing themselves to work in the UK.


Clinical Reviews

Mortality risk highest on the day of birth — unless you live till your nineties

25 Jul 2014Registered users

The risk of a baby in the UK dying on the first day of life is higher than the average daily risk of death until the 92nd year, a study in the BJOG has shown. The study from Nottingham looked at the risk of death on the day of birth, measured in MicroMorts, and compared this with risks at other ages and for a variety of activities. A MicroMort is a figure expressed as the number of one in a million chances of death associated with an activity or event.

Does exercise affect prognosis in coronary heart disease?

25 Jul 2014Registered users

Moderately frequent strenuous activity can reduce cardiovascular risk in patients with stable coronary heart disease (CHD) but daily strenuous activity may increase risk although not as much as no exercise at all, a study suggests. The study analysed data from a prospective cohort of 1,038 subjects with stable CHD. The majority of the participants were male, over 60 (median 61 years), overweight, current or former smokers and had a history of myocardial infarction and hypertension.



Urgency urinary incontinence the most bothersome LUTS

25 Jul 2014Registered users

This study, from Finland, compared the impact of different lower urinary tract symptoms (LUTS). A total of 3,727 individuals took part, just over half were women. On an individual level, urgency urinary incontinence was the most likely symptom to be rated as bothersome by both men and women, with 30.7% reporting at least moderate bother. It is not the presence of symptoms but the bother they cause the patient that is vital to understand when assessing and managing LUTS. Storage symptoms, particularly urgency and urgency urinary incontinence, are the most likely to cause significant impairment of quality of life.

Women with diabetes at greater risk of CHD than men

23 Jun 2014Registered users

A recent large meta-analysis has confirmed that women with diabetes have more than a 40% higher risk of incident coronary heart disease (CHD) than men. For GPs this is a timely reminder to consider CHD as a high risk in women with diabetes, and to treat risk factors vigorously. This is especially important because routine screening in the healthy population accustoms us to women being generally at lower risk than men using the current CHD risk tools.


Symposium articles: Gastroenterology

Early endoscopy improves survival in gastric cancer

25 Jul 2014Registered users

Gastric cancer often presents late and the mortality ratio remains one of the highest compared with more common cancers. Early diagnosis improves survival in this potentially curable cancer. Dysphagia, weight loss and age over 55 are significant predictors of cancer. All patients presenting with dyspepsia and either alarm features or known conditions that increase the risk of gastric cancer should be referred for urgent endoscopy. Given that the majority of gastric cancer cases occur in people over 55, urgent endoscopy is also recommended in patients in this age group with new uncomplicated dyspepsia prior to treatment, even without alarm symptoms or if the symptoms respond to treatment. [With external links to current evidence and summaries]

Detecting patients with cirrhosis in primary care

25 Jul 2014Registered users

Cirrhosis is a condition that arises as a result of chronic liver damage, typically over many years. It is characterised by fibrosis and nodularity of the liver parenchyma. Common causes of chronic liver disease include alcohol, non-alcoholic fatty liver disease and chronic viral hepatitis. Nearly half of patients with cirrhosis are asymptomatic. As a result the condition may only be discovered incidentally as a result of abnormalities in liver function tests or imaging of the abdomen performed for other reasons. Alternatively patients may present with signs and symptoms of the complications of cirrhosis e.g. jaundice, ascites, variceal bleeding, hepatic encephalopathy or hepatocellular carcinoma. The gold standard test for the diagnosis of cirrhosis remains a liver biopsy.


Special reports

Improving outcomes for patients with obesity

25 Jul 2014Registered users

In England there has been a sharp increase in the prevalence of overweight and obesity in adults. In 1993 58% of men and 49% of women were classified as overweight or obese compared with 65% and 58% respectively in 2011; 24% of men and 26% of women were classed as obese in 2011. Obesity increases the risk of diabetes, hypertension, coronary heart disease, deep vein thrombosis and pulmonary embolism. It is also associated with an increased risk of certain cancers. Lifestyle weight management programmes should be multicomponent, developed by a multidisciplinary team, and delivered by individuals who have undergone appropriate training. They should focus on long-term weight loss and prevention of weight regain and continue for a minimum of three months.

Identifying the causes of contact dermatitis

23 Jun 2014Registered users

Contact dermatitis results from skin contact with an exogenous substance. It can be caused by direct contact, airborne particles, vapours or light. Individuals of any age can be affected. The two most common variants are irritant contact dermatitis (ICD) and allergic contact dermatitis (ACD). ICD is more common and has a worse prognosis. ICD is a form of eczema and is induced by direct inflammatory pathways without prior sensitisation. If eczema is recurrent/persistent, or occurs in an individual with no previous history of eczema, contact dermatitis should be considered. If ACD is suspected the patient should be referred to secondary care for patch testing.


A hundred years ago

Treatment of wounded soldiers

25 Jul 2014Registered users

The results of abdominal wounds are very bad. One school of thought recommends immediate operation; the other advises no operation at all. Consider what it means to operate on the abdomen. There must be an absolutely first-class hospital and a first-class nursing staff at our disposal for at least 1½ hours, whilst for each case three highly-skilled medical men are needed: an expert abdominal surgeon – a man who can really tackle big abdominal work, a first-class anaesthetist, and the surgeon’s assistant. In the end, perhaps one out of three, perhaps one out of five, may recover. It is a terrible thing to have to place a man’s life in the balance, when we think we could save it by a great effort. But when there are 50 or 60 other wounded men lying around, and the labour being expended on one may mean lack of attention to the others, it becomes a very difficult question.

Psychological aspects of food idiosyncrasies in infants

23 Jun 2014Paid-up subscribers

In older individuals, in whom the powers of reason have become developed, the direct influence of suggestion may be counteracted by innumerable inhibitions, but in babies, animals and hypnotized individuals the call of suggestion is imperative, and the exact form the response takes is determined by the nature of the previous responses, in other words by habit.


Online only

Special Interest - Cancer and palliative care 4 - 2013

14 Jan 2014Paid-up subscribers

This document can be saved directly into your personal development plan folder on your computer or for review in the PDF reader on your tablet computer.

  • Editorial: Are 5-ARIs suitable for prevention of prostate cancer?
  • Editorial: PSA in men in their 40s predicts risk of prostate cancer deaths
  • Improving the detection and treatment of liver cancer
  • GPs have key role in early detection of melanoma
  • Advances in the treatment of metastatic prostate cancer

Special interest: Dermatology 2 - 2013

13 Jan 2014Paid-up subscribers

This document can be saved directly into your personal development plan folder on your computer or for review in the PDF reader on your tablet computer.

  • Alopecia areata:more than skin deep
  • GPs have key role in early detection of melanoma
  • Intense nocturnal itching should raise suspicion of scabies
  • Improving outcomes in patients with psoriasis


HASLAM's view

Technology can improve the doctor-patient relationship

25 Jul 2014Registered users

The potential for apps and add-ons to smart phones is almost beyond imagination. Patients will be able to download user-friendly health information that will radically change the relationship between doctor and patient to a much healthier partnership model, rather than the teacher/student, priest/supplicant hierarchical model that is still all too typical. However complex and digital and networked the world becomes, human beings will still need to feel safe and cared for. People who are ill will still be frightened, need someone to trust, and need a system that cares. We must never forget that.


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Skin malignancy

25 Jul 2014Registered users

• Acanthosis nigricans • Morphoeic basal cell carcinoma • Primary cutaneous anaplastic large cell lymphoma • Amelanotic melanoma • Dermatofibrosarcoma protuberans • Squamous cell carcinoma [With external links to current evidence and summaries]

Lumps and bumps

23 Jun 2014Registered users

  • Haematoma
  • Furuncle
  • Prayer nodule
  • Pilomatrixoma
  • Umbilical granuloma
  • Neurofibroma

CPD exercises associated with each issue

CPD exercise - July/August 2014

25 Jul 2014Paid-up subscribers

The study pack contains this month’s CPD exercise plus all relevant articles: • Detecting patients with cirrhosis in primary care • Early endoscopy improves survival in gastric cancer • Improving outcomes for patients with obesity. This CPD study pack can be saved directly into your personal development plan folder on your computer or for review in the PDF reader on your tablet computer.

CPD exercise - June 2014

23 Jun 2014Paid-up subscribers

The Practitioner's CPD exercise this month is based on: • Be vigilant for invasive meningococcal disease • Diagnosing and managing peanut allergy in children • Identifying the causes of contact dermatitis. This CPD study pack can be saved directly into your personal development plan folder on your computer or for review in the PDF reader on your tablet computer.


Primary Care Urology Society (UK)

Primary Care Urology Society

Call for GPs with an interest in urology/men’s health

 Dr Jon Rees, a GPwSI urology who writes The Practitioner's clinical reviews in this area, is looking at setting up a Primary Care Urology Society. The organisation would develop an educational programme to support GPs in their work in primary care and in other GPwSI roles.

Membership would be open to all GPs who wish to extend their education in this field beyond that of a standard generalist, not just GPwSIs.

There is also the potential of affiliating the group with the British Association of Urological Surgeons which would allow collaboration between primary and secondary care.

To register your interest please email drjonrees@gmail.com



A case of recalcitrant bacterial conjunctivitis

05 Dec 2013Paid-up subscribers

It is important to be vigilant for retained foreign bodies as a cause of recalcitrant bacterial conjunctivitis, even in the absence of foreign body sensation. A relapsing-remitting history should prompt referral to an ophthalmology department. All patients presenting with a red eye should be asked specifically about contact lens wear, and causes of conjunctivitis other than those bacterial in nature — such as viral and chlamydial infections or allergy — should be borne in mind.

A case of persistent hemifacial weakness

25 Jul 2013Paid-up subscribers

Bell’s palsy has a typical presentation of sudden onset, mild otalgia, altered facial sensation and/or taste, with no obvious prodrome. It represents over half of hemifacial weakness cases in primary care. However, as a diagnosis of exclusion, there are a number of key clinical features of more sinister diagnoses that must be considered.