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 fillable PDF 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.



Managing osteoporosis in postmenopausal women

22 Mar 2018Registered users

Most patients with osteoporosis are asymptomatic unless a fragility fracture occurs. A fragility fracture is a type of pathological fracture that occurs as a result of normal activities, such as a fall from standing height or less, lifting, or bending. There are three fracture sites said to be typical of fragility fractures: vertebral fractures; fractures of the neck of the femur; Colles’ fracture of the wrist. Following fracture risk assessment a dual energy X-ray absorptiometry (DXA) scan may be recommended.

Symptom recognition key to diagnosing endometriosis

22 Mar 2018Registered users

Endometriosis affects around one in ten women of reproductive age in the UK. NICE guidance highlights the importance of symptoms in its diagnosis. A normal abdominal or pelvic examination, ultrasound, or MRI should not exclude the diagnosis. Endometriosis should be suspected in women and adolescents who present with one or more of: chronic pelvic pain, significant dysmenorrhoea, deep dyspareunia, period-related or cyclical GI or urinary symptoms, or infertility. If endometriosis is suspected or symptoms persist, patients should be referred for further assessment.

Prompt investigation improves outcomes for kidney cancer

22 Feb 2018Paid-up subscribers

Renal cell carcinoma should be suspected in the presence of: localising symptoms such as flank pain, a loin mass or haematuria; constitutional upset including weight loss, pyrexia and/or night sweats; or unexplained test results. Smoking, obesity and hypertension are common risk factors and all three demonstrate a dose-response relationship with the relative risk of renal cell carcinoma.

Visible and non-visible haematuria may herald serious disease

22 Feb 2018Paid-up subscribers

Both visible (VH) and non-visible haematuria (NVH) may herald serious pathology e.g. malignancy or vasculitis. All patients with VH or symptomatic NVH should have urinalysis, urinary protein estimation (albumin:creatinine or protein:creatinine ratio), and a renal function test. These should also be requested if asymptomatic NVH persists, i.e. in two out of three samples over 6-8 weeks.

Timely diagnosis of vascular dementia key to management

23 Jan 2018Paid-up subscribers

Vascular dementia is the second most common type of dementia, after Alzheimer’s disease, and accounts for 15% of cases. The core diagnostic features include cognitive impairment in at least two domains (orientation, attention, language, visuospatial function, executive function, motor control and praxis), which affect social or occupational function, together with evidence of cerebrovascular disease (focal neurological signs or neuroimaging). Crucially there should be a temporal relationship between cerebrovascular disease and the onset of cognitive changes.

Pulmonary rehabilitation improves exercise capacity and quality of life

23 Jan 2018Paid-up subscribers

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.


Special reports

Pruritus may be a symptom of underlying systemic disease

22 Mar 2018Registered users

Itch is a common symptom of many dermatological conditions (e.g. eczema, urticaria and lichen planus) but can also be a manifestation of underlying systemic, neurological and psychological disorders, or an adverse reaction to medication. The assessment of patients with generalised itch but no rash requires a detailed history and examination to narrow the spectrum of potential causes. Examination should include inspection of the entire skin. Physical examination should include palpation for lymphadenopathy and organomegaly.

Diagnosis and management of oesophageal cancer

22 Feb 2018

Oesophageal cancer commonly presents with dysphagia or odynophagia and can be associated with weight loss and vomiting. Referral for urgent endoscopy should always be considered in the presence of dysphagia regardless of previous history or medication. NICE recommends urgent referral (within 2 weeks) for direct access for upper GI endoscopy in patients with dysphagia and those aged 55 years or over with weight loss and any of the following: upper abdominal pain, reflux, or dyspepsia.

Diagnosing and managing sepsis in children

23 Jan 2018Paid-up subscribers

The clinical features of sepsis are: fever; tachycardia, with no other explanation; tachypnoea, with no other explanation; leukocytosis or leucopenia. To meet the International Pediatric Sepsis Consensus Conference definition, a patient should have two of these features, one of which should be fever or abnormal white cell count, in the presence of infection. Every time a child who has symptoms or signs suggestive of infection is assessed, it is important to consider whether this could be sepsis. This may seem obvious in a child presenting with fever, but not all children with sepsis present with high fever or focal signs.

Non-motor symptoms may herald Parkinson’s disease

20 Dec 2017Paid-up subscribers

While the three cardinal motor symptoms of Parkinson’s disease (PD), bradykinesia, rigidity and tremor, are key to the diagnosis of the condition, there is evidence that non-motor symptoms start long before motor features arise. Two of these in particular, REM sleep behaviour disorder and olfactory dysfunction, have been strongly associated with the development of PD. Non-motor symptoms are increasingly recognised as main features of PD with a high impact on quality of life. Their progression has been shown to be independent of motor deterioration. Sleep, GI and attention/memory problems become more prevalent over time, whereas psychiatric and cardiovascular problems become less prevalent.

Recognising the pattern of hair loss key to managing alopecia

23 Nov 2017Paid-up subscribers

Alopecia affects up to 50% of men and women at some time in their lives. In primary care the first step is to establish whether hair loss is focal or diffuse and if focal whether it is scarring or non scarring. It is usually possible to establish the pattern of hair loss from a combination of the history and clinical examination. Dermatoscopic examination and pull testing can be useful in confirming the diagnosis. If hair loss is accompanied by scaling or significant inflammation it is important to exclude infective causes.


Clinical reviews of research - by GPs with interest

Quitting smoking improves survival in patients with lung cancer

22 Mar 2018Registered users

Patients with lung cancer who stop smoking have lower all cause mortality rates compared with those who continue to smoke, a UK retrospective cohort study has found.

Comparing cardiovascular outcomes in different diabetes drug classes

22 Mar 2018Registered users

Canagliflozin was associated with a lower risk of heart failure admissions compared with other classes of diabetes drugs, in a population-based retrospective cohort study from the United States.

Women with endometriosis at raised risk of ovarian cancer

22 Mar 2018Registered users

The risk of ovarian cancer is increased in women with endometriosis, a large cohort study from Scotland has shown. The study also found that women with endometriosis are likely to undergo more surgical procedures compared with women who do not have the condition.

Postnatal depression may have adverse effects on offspring

22 Mar 2018Registered users

The children of women with severe persistent postnatal depression (PND) are at substantially increased risk of preschool behaviour problems, poor academic attainment and adolescent depression, a UK longitudinal cohort study has found.


A hundred and fifty years ago

Remarkable cases of senile delirium

22 Mar 2018Registered users

I was sent for early in the morning, and was told she had not had any sleep during the night, but had been talking incessantly. When I saw her she was sitting up in the bed and was rambling incoherently, but everything she uttered was in rhyme, and the ingenuity she displayed in promptly finding the rhyme was very remarkable. During the whole of her illness, which lasted a week, I never once found her at fault in this respect, and she never was more at a loss to give utterance to her thoughts in rhyme than if she had expressed them in the ordinary mode of conversation. She gradually sank, apparently from exhaustion and having talked herself to death.


A hundred years ago

Spinal concussion in warfare cured by suggestion

22 Mar 2018Registered users

Able seaman, J.C., aged 23 years, was a member of a gun’s crew during an action, in which our own and enemy light forces were concerned. A direct hit was obtained by the enemy on his gun,  and all the crew but himself were killed. He was thrown to the deck unwounded, but on regaining his feet an explosion  occurred, caused by a torpedo, and he was thrown into the sea. He began to swim, and succeeded in regaining the ship which was still above water, but she sank within a few minutes. He jumped overboard before she went down and began to swim again; a dull explosion took place almost immediately, whereupon he felt a severe pain in his back and lost consciousness. He stated that he thought he heard other men in similar plight around him cry out just before he became unconscious, but recollected nothing else until he found himself on shore.



Intensive weight management can achieve remission in type 2 diabetes

24 Apr 2018Paid-up subscribers

Almost half the patients in a UK primary care-led weight management programme achieved remission of their type 2 diabetes after a year, a study in the Lancet has shown. Forty-nine general practices in Scotland and Tyneside took part in the DiRECT study, an open label, cluster randomised trial.

Pre-eclampsia may raise risk of autism spectrum disorder

22 Mar 2018Registered users

Maternal pre-eclampsia is associated with an increased risk of autism spectrum disorder (ASD) in offspring, a meta-analysis has found. Compared with unexposed offspring, children who were exposed to pre-eclampsia in utero were 32% more likely to develop ASD.


HASLAM's view

GPs must always be vigilant for the rare bird

24 Apr 2018Registered users

Isn’t it frustrating how the most complex and rare  conditions can turn up when you are least expecting them? One fact that we must never ever forget is that even the world’s rarest condition will affect a patient who has a GP.

Are all GPs hypochondriacs?

22 Mar 2018Registered users

I’ve never quite understood why every doctor isn’t a hypochondriac. Or maybe the rest of you are, but you hide it rather better than I do. I have had more potentially fatal conditions in the course of 24 hours than anyone I have ever known.


CPD exercises associated with each issue

CPD exercise - March 2018

22 Mar 2018Paid-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:• Symptom recognition key to diagnosing endometriosis • Managing osteoporosis in postmenopausal women • Pruritus may be a symptom of underlying systemic disease


Photoguide selection - with PubMed links

Allergic reactions

24 Sep 2015

• Fixed drug eruption • Fabric plaster reaction • Latex allergy • Morbilliform drug reaction • Allergic conjunctivitis • Anaphylaxis

Urgent referrals

23 Mar 2011

• Eczema herpeticum • Pemphigus vulgaris • Perinephric abscess • Quinsy [with pre-set links to the evidence base]