The Practitioner

The Practitioner contributes to the formal clinical literature and is primarily aimed at GPs, with subscribers throughout the World. 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

Treating to target will optimise long-term outcomes in RA

24 Nov 2020Paid-up subscribers

Rheumatoid arthritis (RA) classically causes a symmetrical, small joint polyarthritis  which left untreated can lead to joint destruction and deformity. Patients typically present with stiffness, pain and swelling of the small joints in the hands and wrists (metacarpophalangeal and proximal interphalangeal joints) which may lead to functional impairment. However, RA can affect any synovial joints, apart from sparing the distal interphalangeal joints. RA is relatively common, with  a prevalence of around 1%, and women are more commonly  affected than men. Median age of onset is 58 years. There is no universally agreed age classification in RA, some classify over 60 as late onset whereas others have used the median age as a cut-off between late onset and young onset.

Diagnosis and management of Paget’s disease of bone

24 Nov 2020Paid-up subscribers

Paget’s disease of bone is a metabolic disease in which focal abnormalities of bone remodelling occur in one or more skeletal sites. The affected bones enlarge and may become deformed and this can lead to complications including bone pain, pathological fractures, secondary osteoarthritis, deafness and nerve compression syndromes. Paget’s disease is seldom diagnosed below the age of 50 but the incidence doubles every 10 years thereafter to 5-7/10,000 population per year by the ninth decade in the UK. The most common presenting features in those that do present clinically are bone pain (52.2%), bone deformity (21.5%), deafness (8.9%) and pathological fractures (8.5%). Rarely, Paget’s disease may present with osteosarcoma (0.3% of patients).

Suspected cardiac syncope requires urgent investigation

27 Oct 2020Paid-up subscribers

Around 40% of people experience a syncopal event during their lifetime. Cardiac syncope accounts for 10% of presentations. Incidence rises significantly with age. Assessment should be systematic: a thorough history, physical examination including lying and standing BP and 12-lead ECG. The medical history and physical examination are key. If following initial assessment cardiac syncope is suspected patients should be referred for urgent specialist cardiovascular assessment or emergency admission.

Diagnosis and management of abdominal aortic aneurysm

27 Oct 2020Registered users

Risk factors for abdominal aortic aneurysm formation include: smoking, increasing age, and family history. Men over the age of 65 are most commonly affected, with an abdominal aortic aneurysm present in approximately 1%. As the condition is normally asymptomatic, most patients have their aneurysms discovered through the screening programme or incidentally via other imaging investigations. Patients with a new diagnosis of an abdominal aortic aneurysm should be referred to their local vascular service.

Detailed history the cornerstone of epilepsy diagnosis

24 Sep 2020

The incidence of epilepsy in the UK is estimated to be 50 per 100,000 per year and up to 1% of the population have active epilepsy. The diagnosis of epilepsy will usually be made in a neurology clinic. A generalised seizure as part of a generalised epilepsy syndrome may occur without warning but may be preceded by blank spells or myoclonic jerks. A generalised seizure with focal onset may be preceded by an aura. Brain imaging is required in almost all cases where epilepsy is suspected, the only possible exception being people with generalised epilepsies proven on EEG. MRI is the imaging modality of choice.

GPs should be vigilant for acute deterioration in myasthenia gravis

24 Sep 2020Registered users

Myasthenia gravis is an autoimmune disorder of neuromuscular junction transmission. It is relatively rare, with an approximate annual incidence of 1 per 100,000 population, and prevalence of 15 per 100,000 population in the UK. An ocular presentation may include fatiguing ptosis or diplopia. Typically, symptoms ‘fatigue’ (the physical power of the muscle deteriorates rapidly with repeated activity) and become more noticeable as the day progresses. More generalised symptoms include fatiguing difficulty with speech or swallowing. There may be fatiguing weakness of the arms and legs. The diagnosis will usually be confirmed by referral to a neurologist. 


Special reports

Prompt diagnosis can improve outcomes in multiple sclerosis

27 Oct 2020Registered users

Multiple sclerosis (MS) is the leading cause of non-traumatic neurological disability in young adults. Between 1990 and 2016, the UK prevalence increased by 28%, due to earlier diagnosis and increased survival. The female to male ratio is 2:1, and patients have a minimally reduced life expectancy. Diagnostic criteria require that clinical, radiological and laboratory signs of MS are disseminated in both time and space. Diagnosis is based on a combination of features (relapses and clinical progression), MRI findings, and CSF analysis.

Optimising the management of diverticular disease

24 Sep 2020Registered users

Diverticular disease is characterised by intermittent abdominal pain in the left lower quadrant of the abdomen associated with constipation or diarrhoea. It can be difficult to differentiate from other conditions such as colitis, irritable bowel syndrome and colorectal cancer. Acute diverticulitis typically presents with severe constant left lower quadrant pain associated with signs of systemic upset such as fever. The patient may also have a change in bowel habit or rectal bleeding. On examination there is tenderness in the left lower quadrant. Acute diverticulitis may be complicated by perforation, abscess, fistula formation, bleeding or a stricture.


Women's health -Temporary direct access

Investigating the cause of heavy menstrual bleeding

25 Mar 2019

Heavy menstrual bleeding has been defined as ‘excessive menstrual blood loss which interferes with a woman’s physical, social, emotional, and/or material quality of life’. Heavy menstrual bleeding affects 25% of women of reproductive age and is estimated to be the fourth most common reason for gynaecological referrals. Women should be asked about pelvic pain which might suggest endometriosis and pressure symptoms which might suggest significant fibroids. Examination is appropriate if there is intermenstrual or postcoital bleeding and, if the woman is actively bleeding, may identify the source of the bleeding.

Symptom recognition key to diagnosing endometriosis

22 Mar 2018

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 treatment of impetigo reduces risk of spread

22 Jun 2020Paid-up subscribers

Impetigo is a common contagious bacterial infection of the skin. The causative organisms are either Staphylococcus aureus or, less commonly, Streptococcus pyogenes. The infection can occur at any age, but it is particularly common in children, especially the pre-school and early school age years, and tends to be more frequent during the summer months. It may arise on previously normal skin or complicate a pre-existing dermatosis. The diagnosis is essentially a clinical one, but if in doubt a swab should be taken for bacteriological culture.

Improving the detection and management of peanut allergy

25 May 2020Registered users

Peanut allergy currently affects around 2% of the population. It is the most common cause of fatal food related anaphylaxis. Most patients (80%) will have long-lived peanut allergy. Primary peanut allergy most commonly presents in the first 5 years of life after the first known exposure to peanut. Clinical features are those of an IgE-mediated reaction. All patients with a history suggestive of peanut allergy should be referred to an allergy clinic for comprehensive assessment and management.

Early recognition key in child and adolescent anxiety disorders

23 Apr 2020Registered users

Anxiety disorders are common, highly treatable conditions, with a strong evidence base for cognitive behaviour therapy. In a recent population sample of the under 12s, only 65% of those who met criteria for a diagnosis of an anxiety disorder had sought professional help and only 3.4% had received an evidence-based treatment. Assessment should include an exploration of neurodevelopmental conditions, drug and alcohol misuse, and speech and language problems.

Improving outcomes in allergic rhinitis in children

24 Jun 2019Paid-up subscribers

Allergic rhinitis can affect a child’s physical health, reduce their quality of life, sleep and concentration, and impact on school performance. Children with allergic rhinitis are at increased risk of developing asthma. Around 85% of those with asthma have allergic rhinitis, which can complicate diagnosis and management and also increase the risk of hospitalisation for asthma exacerbations. However, appropriate management of allergic rhinitis can improve asthma control. The diagnosis of allergic rhinitis can usually be made on the basis of the patient’s history and examination alone. 



Treating psychological trauma in the real world

23 Jan 2020

After a potentially traumatic event (PTE), many individuals experience either no distress or only transient distress, while others suffer considerable morbidity and may develop post-traumatic stress disorder (PTSD). Around one-third of people experiencing a PTE will develop PTSD, though this varies depending on the type of traumatic event and rates of PTSD are higher with type 2 trauma. Type 2 trauma involves repeated traumatic experiences over extended periods. Although PTSD symptoms can be present acutely, the diagnosis requires the persistence of symptoms for at least one month and the symptoms should cause functional impairment.

Early intervention key in first episode psychosis

20 Dec 2019

Psychosis is a state of mind in which a person loses contact with reality in at least one important respect while not intoxicated with, or withdrawing from, alcohol or drugs, and while not affected by an acute physical illness that better accounts for the symptoms. Common positive symptoms of psychosis include delusions and hallucinations. These symptoms are strongly influenced by the underlying cause of the psychosis: delusions in schizophrenia tend to be bizarre; delusions in depression negative; delusions in mania expansive. When a patient presents with psychotic symptoms, it is important to take a full psychiatric history, perform a mental state examination and complete relevant investigations, as indicated in each individual case.



Cardiovascular risk assessment vital in patients with rheumatoid arthritis

24 Nov 2020Registered users

Patients with rheumatoid arthritis (RA) have an excess of stroke and heart failure which appears to accumulate in the five years before diagnosis, an English population-based study has found. The excess risk for further cardiovascular disease (CVD) events persisted after diagnosis and was not totally explained by differences in traditional CVD risk factors or RA-related risk factors at diagnosis.

Is opportunistic screening for AF in general practice worthwhile?

27 Oct 2020Registered users

Screening patients opportunistically in primary care does not improve detection of atrial fibrillation, compared with usual care, a cluster randomised controlled trial from the Netherlands has found.


Research reviews - by GPs with a special interest

Corticosteroid therapy for asthma raises risk of osteoporosis and fragility fractures

27 Oct 2020Registered users

Use of oral or inhaled corticosteroids appears to be an independent risk factor for osteoporosis and fragility fractures in patients with asthma, a UK population-based study has found.

Prediabetes associated with increased risk of CVD and all-cause mortality

27 Oct 2020Registered users

A meta-analysis has shown an association between prediabetes and raised risk of all-cause mortality and incident cardiovascular disease in the general population as well as patients with atherosclerotic heart disease.


HASLAM's view

A house call I’ll never forget

24 Nov 2020Registered users

I will never forget that day in George’s house. He was 52 and had developed a particularly aggressive cancer three years earlier. He had shown tremendous bravery and had withstood and appreciated everything that high-tech hospital medicine could throw at him. Now it looked like we were near the end of the road. On his last visit to the hospital he had been told that his secondaries were widespread, and that the armoury of potential treatments had been exhausted. There was nothing else that could be done from a curative point of view.


A hundred and fifty years ago

Extracts from British and foreign journals - 1870

27 Oct 2020Registered users

Extraction of a pin from the urethra: M. Ticier reports a case in which a boy, aged 7,  introduced, at the encouragement of a school-fellow, a pin into his urethra. It slipped from his hand, and as usual retreated along the passage. 

A plan for reducing dislocation of the shoulder by Mr Lowe. 

On the therapeutic value of gastric juice: Signor Arturo Menzel supports the experiments and results of older experimenters in regard  to the value of gastric juice in cancerous tumours, and has collected a considerable number of cases in which it has been employed with advantage, either in true cancer or in lymphoma


A hundred years ago

Counter-irritation, by blister or percussion, in spinal therapeutics

27 Oct 2020Registered users

M.B., 22, had suffered from trench feet in January, 1916, for which he had been in hospital for six months. He applied for treatment last summer on account of pain in his feet describing his condition as if he were “walking on hot plates.” The pain would generally last for half an hour to four hours, though occasionally it might be present for a whole day. After a few séances of percussion of the seventh cervical spine, complete freedom from discomfort ensued.


Cancer - Temporary direct access

Optimising the management of early prostate cancer

23 Apr 2020

Men born after 1960 in the UK now have a 1 in 6 estimated lifetime risk of being diagnosed with prostate cancer. NICE recommends that men over 50 years old who request a PSA test should be fully counselled about the test beforehand. The test should also be offered to men with LUTS or an abnormal DRE. If the prostate feels malignant on DRE this should trigger a fast track referral to secondary care, via a suspected cancer pathway referral, even if the PSA is normal. Men with PSA values above the age-specific reference range should also be referred to urology urgently, via a suspected cancer pathway referral.

Time to diagnosis key in improving lung cancer outcomes

25 Nov 2019

NICE recommends urgent referral via a suspected cancer referral pathway to the two week wait service if: chest X-ray findings suggest lung cancer or if patients aged 40 and over have unexplained haemoptysis. However, studies have indicated that around 20-25% of patients with confirmed lung cancer may have a chest X-ray reported as normal and this figure may be higher for early stage lung cancers. Therefore, the National Optimal Lung Cancer Pathway recommends that where there is a high suspicion of underlying malignancy (but the chest X-ray is normal), GPs should refer patients directly for a CT scan.