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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The role of PSA in detection and management of prostate cancer

25 Apr 2016

The prostate specific antigen (PSA) test clearly provides the opportunity for clinically relevant prostate cancer to be detected at a stage when treatment options are greater and outcomes may be improved. In addition, a raised PSA may often indicate benign prostatic enlargement, and this may provide an opportunity for treatment of this condition before complications develop. However, in some patients the PSA test may lead to investigations which can identify clinically insignificant cancers which would not have become evident in a man’s lifetime.

Managing lower urinary tract symptoms in men

25 Apr 2016Registered users

Up to 90% of men aged 50 to 80 may suffer from troublesome LUTS. A thorough urological history is essential to inform management. It is important to determine whether men have storage or voiding LUTS or both. Based on history, examination and investigation findings an individualised management plan should be formulated.


A hundred years ago

Difficult dislocations

25 Apr 2016Paid-up subscribers

DISLOCATIONS, even rare ones, have a knack of cropping up in general practice. One of the most unmanageable and disastrous is undoubtedly congenital dislocation of the hip. Failures gall me, as I suppose they do most people, and the verdict, “Nothing can be done,” always, I fear, arouses my obstinacy.


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. Thunderclap headaches may be associated with symptoms such as photophobia, nausea, vomiting, neck pain, focal neurological symptoms or loss of consciousness. Subarachnoid haemorrhage (SAH) accounts for 10-25% of all thunderclap headaches and, despite advances in medical technology, has a 90-day mortality of 30%. Up to a quarter of cases of SAH are misdiagnosed, often through failure to follow guidance.


Early diagnosis of oesophageal cancer improves outcomes

21 Mar 2016

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.


Cardiovascular medicine

Underestimating risk in women delays diagnosis of CVD

21 Mar 2016

CVD remains the most common cause of mortality in women. There has been an increase in the prevalence of MI in women aged 35 to 54, while a decline in prevalence was observed in age-matched men. Although men and women share classic cardiovascular risk factors the relative importance of each risk factor may be gender specific. The impact of smoking is greater in women than men, especially in those under 50. Diabetes is a more potent risk factor for fatal CHD in women than men.

Management of heart failure with preserved ejection fraction

21 Oct 2015Registered users

Heart failure affects nearly one million people in the UK. Half of these patients have normal, or near normal, left ventricular ejection fraction and are classified as heart failure with preserved ejection fraction (HFpEF). Newer imaging techniques have confirmed that systolic function in HFpEF patients is not completely normal, with reduced long axis function and extensive but subtle changes on exercise. Patients are likely to be older women with a history of hypertension. Other cardiovascular risk factors, such as diabetes mellitus, atrial fibrillation and coronary artery disease are prevalent in the HFpEF population.



Optimising the management of bronchiolitis in infants

05 Aug 2015

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

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.



Antidepressants and cardiovascular risk

23 May 2016Registered users

Selective serotonin reuptake inhibitors (SSRIs) are not associated with an increased risk of cardiovascular events in younger adults with depression, a UK cohort study has found.Overall, 209,476 (87.7%) patients received at least one prescription for an antidepressant during the follow-up period. Nearly three-quarters (71.3%) of prescriptions were for SSRIs, 16.0% were for tricyclics and 12.7% were for other antidepressants. Compared with periods of no antidepressant treatment, periods of SSRI treatment were not associated with an increased risk of arrhythmia, stroke or TIA. In the first year of follow-up, SSRI treatment was associated with a significantly reduced risk of myocardial infarction.

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

Making the same mistakes with ever increasing confidence probably applies to the way that many of us practise, or have practised, medicine. It’s a hard thing to admit, and probably a very hard thing to recognise. After all, if you do something that isn’t quite right – something as simple as taking a very minimal short cut – and you get away with it, then whether you are skiing or practising medicine the likely outcome is that you will keep doing it.



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.


Painful conditions

Evaluating the patient with low back pain

22 Dec 2015Registered users

In the UK, low back pain is the most common cause of disability in young adults and every year 6-9% of adults consult their GP about back pain. A thorough history and examination is required to exclude an alternative diagnosis, such as pain arising from the hip or trochanteric bursa and to categorise patients as having: serious spinal pathology, nerve root/radicular pain or non-specific back pain. [With pre-set searches of the evidence base]

Patients with gout can be cured in primary care

15 Dec 2014Paid-up subscribers

Gout is associated with comorbidities such as nephrolithiasis, chronic renal impairment, metabolic syndrome, depression and heart disease. It is also associated with increased mortality. Untreated gout can result in disabling irreversible peripheral joint damage and chronic usage-related pain. However, gout is curable.  [With external links to the evidence base]



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.


CPD exercises associated with each issue

CPD exercise - April 2016

25 Apr 2016Paid-up subscribers

CPD exercises in The Practitioner online now include CPD prompt frameworks for personal reflection on learning and drafting of plans. 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 here in our standard study pack containing 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.