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

Tight blood pressure control key in polycystic kidney disease

21 Feb 2021Paid-up subscribers

Polycystic kidney disease (PKD) has an autosomal dominant mode of inheritance. Despite this 25% of patients will have no known family history and these cases are thought to be due to de novo mutations in the causative genes. PKD can present asymptomatically and should be considered in any patient with renal cysts noted on abdominal imaging, especially if there is a history of hypertension. Patients with PKD may present with hypertension before a decline in eGFR is noted. Cyst haemorrhage, rupture or infection can all present with acute loin pain. PKD can also cause a number of extrarenal complications.

Diagnosis and management of age-related macular degeneration

25 Jan 2021Registered users

Age-related macular degeneration (AMD) is a cause of painless, gradual loss of vision. Epidemiological evidence suggests 4-8% of people aged over 65 years in the UK have visually significant AMD. Patients with suspected neovascular AMD (NvAMD) should be seen by ophthalmology within two weeks, and if the diagnosis and progressive disease are confirmed, treatment should commence within the same timeframe. Intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents cause regression of neovascularisation and reduce macular oedema. There is no treatment for dry AMD.

Diagnosing anxiety disorders in older adults can be challenging

25 Jan 2021Registered users

In older adults, the prevalence of anxiety disorders is higher among those with other health problems, and those in hospital and care settings. A primary depressive disorder should be excluded whenever an older person presents with anxiety symptoms for the first time, and comorbid anxiety often indicates a more severe presentation of depression. Around four in five patients have a comorbid physical disorder. Medical conditions can mimic symptoms of, predispose to, or even directly precipitate an anxiety disorder, and may colour its symptomatology or limit treatment options.

Improving the management of chronic asthma in children

21 Dec 2020Paid-up subscribers

There is no gold standard test to diagnose asthma. As a result, overdiagnosis and underdiagnosis are common especially when relying on history and clinical examination alone. Spirometry and bronchodilator reversibility testing are particularly useful when a child aged 5 years or older is brought to the practice with symptoms. The validated Asthma Control Test for children aged 12 years and over and the Children’s Asthma Control Test for children aged 4-11 years should be used to assess current asthma control based on four-week recall. Asthma control test scores correlate poorly with lung function and measures of airway inflammation such as FeNO in children and should not be used in isolation.

Diagnosis and management of malignant pleural mesothelioma

21 Dec 2020

Mesothelioma accounts for less than 1% of all cancers in England, Wales and Northern Ireland. There are almost 2,500 new diagnoses a year, of which 96% are pleural. The median age at diagnosis for malignant pleural mesothelioma (MPM) is 76 years. The majority of cases occur in men, most commonly following occupational exposure to asbestos. There is a latent period, usually 30-40 years, between exposure and disease development. A chest X-ray is usually the first-line investigation; 94% of patients with MPM have a unilateral pleural effusion, although the chest X-ray may be normal or show another asbestos-related lung disease. 


Special reports

Holistic approach needed to tackle chronic primary pain

21 Feb 2021Paid-up subscribers

The International Association for the Study of Pain has developed a new classification system for chronic pain. A fundamental distinction is made between chronic primary pain and chronic secondary pain. Chronic primary pain is defined as pain in one or more anatomical regions that persists for longer than three months, is associated with disability or emotional distress, not better accounted for by another diagnosis of chronic pain. Chronic primary pain is subdivided into five categories. Chronic secondary pain is pain secondary to an underlying disease.

Aetiology key to the management of bronchiectasis

25 Jan 2021Registered users

Bronchiectasis increases in incidence and prevalence with age affecting > 1% of people aged 70 and older. It is associated with significant morbidity and mortality. Bronchiectasis can be congenital or acquired following a lung-damaging event such as severe infection, or have an immunological aetiology, but the cause is not always found. It can be associated with inflammatory bowel disease, rheumatoid arthritis and other connective tissue diseases. Most patients with bronchiectasis present with persistent cough and daily sputum production. Bronchiectasis is diagnosed using high resolution CT.

Psoriatic arthritis often goes unrecognised

21 Dec 2020Registered users

Psoriatic arthritis (PsA) is a seronegative systemic disease that belongs to the family of spondyloarthropathies. Its worldwide prevalence ranges from 0.05% to 1%, and it appears in 10-40% of patients with skin psoriasis; however, it is believed to be underdiagnosed. More than 80% of patients who are diagnosed with PsA already have skin disease, mainly in the form of plaque psoriasis. However, 15% of patients present with musculoskeletal involvement prior to psoriasis which makes the diagnosis of PsA challenging. It is important to do a thorough clinical assessment, take a family history and actively look for evidence of psoriasis: this includes examining nails, the scalp, intergluteal region and umbilicus.

Early symptom recognition key in management of TIA and stroke

24 Nov 2020Registered users

In the UK, at least 100,000 people have an acute stroke each year. A first ever transient ischaemic attack (TIA) affects around 50 people per 100,000 per year and around 15% of people who have a first stroke have had a preceding TIA. Patients with a suspected TIA should be referred immediately for specialist assessment and investigation, to be seen within 24 hours of onset of symptoms. Patients with a suspected stroke should be admitted immediately to hospital, ideally to an acute stroke unit. Patients with a suspected TIA who have a bleeding disorder or are taking an anticoagulant should also be admitted to an acute stroke unit as haemorrhage must be excluded.

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

Tailor treatment to the patient in polycystic ovary syndrome

24 Mar 2020Registered users

Polycystic ovary syndrome is a condition characterised by hyperandrogenism, multifollicular ovaries and ovulatory dysfunction. It affects 8-13% of women of reproductive age and is associated with insulin resistance, hyperlipidaemia and obesity. Baseline measurements should include blood pressure and BMI. Clinical signs of hyperandrogenism including hirsutism, acne and androgenic alopecia should be assessed. A hormone profile should be done during days 1-5 of the menstrual cycle or as a random sample when there is amenorrhoea.

Investigating the cause of heavy menstrual bleeding

25 Mar 2019Registered users

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.



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.

Managing common skin conditions in infants

24 Jun 2019Paid-up subscribers

Atopic eczema, or atopic dermatitis, affects up to 20% of children and often presents in infancy. Cow’s milk allergy can also manifest as eczema and gastrointestinal (GI) symptoms. Food allergy should be suspected if there is a clear history of a reaction to a food in infants with moderate to severe eczema not responding to standard treatment, in infants with very early onset eczema (under 3 months) and those with GI symptoms. Seborrhoeic dermatitis is often an early manifestation of atopic eczema. Naevus simplex is a common congenital capillary malformation occurring in up to 40% of newborns. Port wine stains are less common, affecting about 0.3% of infants. 



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.

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.


Special reports



Loneliness a potential risk factor for depression

21 Feb 2021Paid-up subscribers

Loneliness is associated with an increased risk of developing depression, a longitudinal cohort study has found. The English Longitudinal Study of Ageing (ELSA) recruited 11,391 participants aged 50 years and over who were living in a private household in 2002. Participants were followed up every two years until 2016/17.

Do statins raise the risk of depression?

25 Jan 2021Registered users

Statin use is associated with a reduced risk of depression and does not increase the risk of suicide, anxiety or seizures, a Swedish national cohort study has found.


HASLAM's view

The masked patient presents a new challenge for GPs

21 Feb 2021Paid-up subscribers

I think back on so many of the consultations I had as a doctor where I needed to break bad news or listen to a complex and distressing history. To have these exchanges with patients when both sides are masked and physically distanced makes being a doctor even more challenging than normal.


Research reviews - by GPs with a special interest

Which drugs should be used first line for hypertension?

21 Feb 2021Paid-up subscribers

Tailoring choice of antihypertensives to the patient rather than using strict age criteria might be more beneficial, the authors of a UK observational cohort study suggest.

Preterm birth associated with shorter life span

21 Feb 2021Registered users

Individuals born even slightly prematurely have an increased risk of early death in adult life, a Nordic population-based study has found.

Increased risk of attempted suicide in young problem gamblers

21 Feb 2021Paid-up subscribers

Men and women, under the age of 25, with problem gambling are at increased risk of trying to take their own lives, a UK study has found.

Which treatments are effective for maintaining abstinence from alcohol in primary care?

25 Jan 2021Registered users

Acamprosate was the only intervention with evidence that it was better than placebo in maintaining alcohol abstinence for up to 12 months, following detoxification, in a network meta-analysis.


A hundred and fifty years ago

150 years ago: Ergot of rye in the treatment of recurrent mania

21 Feb 2021Registered users

M.B. ... labours under the distressing idea that her children and relations have been the victims of a foul plot, have been chopped into mincemeat by the officers of the asylum, and that their mutilated remains, tied up in canvas bags, are concealed in the cellars beneath the ward which she inhabits, whence they hourly cry aloud for vengeance.


A hundred years ago

100 years ago: ‘Is cancer a parasitic disease?’

21 Feb 2021Registered users

Leyden and Mauneyne have reported two cases of cancer of the stomach in doctors, one of whom swallowed vomited matter from a cancer patient by mistake, and died of cancer of the stomach, and the other did the same thing voluntarily in order to show that cancer was not contagious, and promptly developed cancer. 


Cancer - Temporary direct access

Diagnosis and management of malignant pleural mesothelioma

21 Dec 2020

Mesothelioma accounts for less than 1% of all cancers in England, Wales and Northern Ireland. There are almost 2,500 new diagnoses a year, of which 96% are pleural. The median age at diagnosis for malignant pleural mesothelioma (MPM) is 76 years. The majority of cases occur in men, most commonly following occupational exposure to asbestos. There is a latent period, usually 30-40 years, between exposure and disease development. A chest X-ray is usually the first-line investigation; 94% of patients with MPM have a unilateral pleural effusion, although the chest X-ray may be normal or show another asbestos-related lung disease. 

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.