The Practitioner

The Practitioner is a PubMed indexed journal primarily aimed in GPs, with subscribers throughout the World. It is also used by doctors preparing for work in the UK. 

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Symposium: Men's health

The role of PSA in detection and management of prostate cancer

25 Apr 2016Registered users

Recently the prostate Cancer risk management Programme (PCRMP) published updated guidance on prostate specific antigen (PSA) testing for primary care and the NHS screening committee has reviewed the evidence surrounding the utility of PSA screening. NICE published updated guidelines on the diagnosis and management of prostate cancer in 2014. There are both advantages and disadvantages for men of having a PSA test, and these should be clearly explained to patients before the test is requested.

Managing lower urinary tract symptoms in men

25 Apr 2016Registered users

Male lower urinary tract symptoms (LUTS) are common and increase in prevalence with age. Up to 90% of men aged 50 to 80 may suffer from troublesome LUTS. Although BPH may cause prostatic enlargement only 25-50% of men with BPH have clinically apparent LUTS. Bladder dysfunction or less commonly urethral pathology also play a role in LUTS and awareness of this interplay is important in the assessment and management of men presenting with urinary symptoms.


Special reports

Rapid diagnosis vital in thunderclap headache

25 Apr 2016Registered users

Thunderclap headache is a severe and acute headache that reaches maximum intensity in under one minute and lasts for more than five minutes. However, the term is often misused to mean any severe headache leading to misdiagnosis and unnecessary investigations. There are national guidelines for the investigation of thunderclap headache, in essence for SAH, but local policies should also be in place. Despite expert opinion that all patients with thunderclap headache should undergo urgent assessment with computerised tomography (CT) brain scan and lumbar puncture (LP) up to a quarter of SAH are misdiagnosed, often through failure to follow these simple recommendations.

Early diagnosis of oesophageal cancer improves outcomes

21 Mar 2016Paid-up subscribers

There are two main types of oesophageal cancer, oesophageal squamous cell carcinoma and oesophageal adenocarcinoma. They present in the same manner and both carry a five-year survival of only 16%. Oesophageal cancer commonly presents with dysphagia or odynophagia. This can be associated with weight loss and vomiting. All patients with recent onset dysphagia should be referred for rapid access endoscopy. Referral for urgent endoscopy should still be considered in the presence of dysphagia regardless of previous history or medication. Dysphagia is not always present so all patients with alarm symptoms should be considered for endoscopy.


Clinical Reviews

What are the benefits of testosterone treatment in older men?

28 Apr 2016Registered users

Testosterone therapy in men 65 and over with low testosterone levels produced moderate improvements in sexual function and some improvement in mood but had no effect on vitality or walking, a study published in the New England Journal of Medicine has found. A total of 51,085 men, aged 65 or older were recruited. Of these, 790 men with a serum testosterone < 275 ng/dl (this equates to < 9.5 nmol/L - the more commonly used unit in UK practice) met the inclusion criteria and were enrolled in the study. All the men had symptoms that could be explained by low testosterone. They were randomised to either testosterone gel or a placebo gel for one year.

Does vasectomy affect sexual function?

28 Apr 2016Registered users

Vasectomy does not appear to be associated with reduced sexual activity, a large study from the United States has found. The study authors used the National Survey of Family Growth (NSFG) dataset comprising 7,643 women and 4,928 men.



Optimising the management of bronchiolitis in infants

05 Aug 2015Registered users

Bronchiolitis shows a seasonal pattern with peak incidence occurring in the winter. Around 2-3% of children require admission to hospital. Admission rates are highest in infants less than three months old and those with underlying comorbidities. Infants will have a coryzal prodrome lasting one to three days before developing a persistent cough.

Diagnosing and managing food allergy in children

22 Jun 2011Paid-up subscribers

Recent studies suggest that the prevalence of food allergy in children in the UK is now around 5%.The number of children put on restricted diets by their parents because of presumed allergy is likely to be much higher. A recent study in the Isle of Wight found that 33% of mothers thought their child had had an allergic reaction to food by the age of three. Careful documentation using a targeted and thorough history usually makes it possible to distinguish suspected IgE-mediated allergy from non IgE-mediated. Once diagnosed, management requires allergen avoidance guided by a dietician together with education in recognising and treating reactions appropriate to the underlying mechanism. Food allergy is commonly outgrown so regular reassessment is essential both to monitor for tolerance and also to look for development of allergic comorbidities. [With external links to the evidence base]


Women's health

Managing debilitating menopausal symptoms

21 Mar 2016Paid-up subscribers

Severity and duration of menopausal symptoms varies markedly. Eight out of ten women experience symptoms and on average these last four years, with one in ten women experiencing symptoms for up to 12 years. Menopausal symptoms can begin years before menstruation ceases. A recent study found that women whose vasomotor symptoms started before the menopause suffered longest, median 11.8 years. Women whose hot flushes and night sweats started after the menopause had symptoms for a median of 3.4 years.

Detecting ovarian disorders in primary care

20 Mar 2014Paid-up subscribers

Ovarian cysts occur more often in premenopausal than postmenopausal women. Most of these cysts will be benign, with the risk of malignancy increasing with age. Symptoms which may be suggestive of a malignant ovarian cyst, particularly in the over 50 age group, include: weight loss, persistent abdominal distension or bloating, early satiety, pelvic or abdominal pain and increased urinary urgency and frequency. [With external links to the current evidence base]



Improving the management of rosacea in primary care

23 Oct 2014Paid-up subscribers

Rosacea is more common in women than men and occurs more frequently in fair-skinned individuals, usually in the middle years of life. It tends to localise to the cheeks, forehead, chin and nose, sometimes showing marked asymmetry. Only very occasionally does it involve areas other than the face. Important distinguishing features from acne are a lack of comedones, absence of involvement of extra-facial areas, and the presence of flushing. Rosacea is a disfiguring condition that can have a major psychosocial impact, and its detrimental effect on emotional health and quality of life is often overlooked.

Identifying the causes of contact dermatitis

23 Jun 2014Paid-up subscribers

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.


CPD exercises associated with each issue

CPD exercise - April 2016 - Launch of fillable PDFs

25 Apr 2016Paid-up subscribers

CPD exercises in The Practitioner online have expanded to prompt the capture of learning notes, personal reflection and drafting of CPD plans through four CPD prompt frameworks. These are fillable PDFs that can be saved with your personal development plan and CPD folder on your device or in your Cloud storage system. All new items are also included in our standard study pack that contains this month’s CPD exercise plus all relevant articles: • Managing lower urinary tract symptoms in men • The role of PSA in detection and management of prostate cancer • Rapid diagnosis vital in thunderclap headache.




Sedentary behaviour associated with type 2 diabetes

25 Apr 2016Registered users

The findings of a large prospective cohort study suggest that sedentary behaviour increases the risk of developing metabolic syndrome and type 2 diabetes. When the data were analysed, increased sedentary time was associated with both metabolic syndrome and type 2 diabetes. An extra hour of sedentary time was associated with 22% increased odds of type 2 diabetes and 39% increased odds of metabolic syndrome, independent of high-intensity physical activity.


HASLAM's view

Keeping yourself on track

25 Apr 2016Registered users

The ability to switch off completely from work is essential for each and every doctor. It doesn’t matter how we achieve this. Some people can switch off completely by lying on a beach, or listening to music. Much as I love both, I find thoughts and anxieties keep muscling their way through. I don’t know about you, but for me relaxation requires activity. Simply stopping and chilling out has the exact opposite effect. We each have to find the method that works for us.



Conditions affecting the hair and scalp

25 Apr 2016Registered users

• Dermatitis artefacta • Alopecia mucinosa • Lichen planopilaris • Discoid lupus erythematosus • Sebaceous naevus • Basal cell carcinoma


Respiratory medicine

Improving the diagnosis and management of COPD

25 Nov 2015Paid-up subscribers

COPD is a progressive condition. Therefore, earlier diagnosis allows earlier intervention in particular smoking cessation. Spirometry should be performed in symptomatic current or former smokers (typically = 10 pack years) who are aged at least 35 where COPD is a likely differential diagnosis.

Optimising the management of patients with difficult asthma

25 Nov 2015Registered users

Between 5 and 10% of asthma (depending on the definition used) is categorised as difficult asthma, a term which generally refers to patients who continue to experience symptoms and frequent exacerbations despite the prescription of high-dose asthma therapy. Difficult asthma is an indication for specialist review by an appropriate respiratory physician, but close liaison between primary, secondary and tertiary care is critical.



Diagnosing and treating diverticular disease

24 Sep 2015Paid-up subscribers

It is important to distinguish between diverticulosis, the presence of asymptomatic diverticula, and diverticular disease which refers to symptomatic cases which can present with acute or chronic symptoms. Diverticular disease can be confirmed radiologically or endoscopically. Even in patients with established diverticulosis, a change in the clinical picture with development of red flag symptoms warrants urgent referral to rule out lower gastrointestinal malignancy.

Diagnosis and treatment of gallstone disease

22 Jun 2015Registered users

Gallstone disease increases with age. Women have a higher prevalence of gallstones than men, which is attributed to exposure to oestrogen and progesterone. Liver function tests and an abdominal ultrasound should be offered to patients with symptoms suggestive of gallstone disease (e.g. abdominal pain, jaundice, fever). They should also be considered in patients with less typical but chronic abdominal or gastrointestinal symptoms.