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

Identifying the cause of late life psychosis

23 Jan 2020Registered users

Late life psychosis may be caused by organic conditions including: delirium, dementia, drug intoxication or withdrawal, or a general medical condition. In these situations there should be evidence of a temporal relationship between the psychosis and the underlying condition. Around 60% of older adults presenting with new onset psychosis have an identifiable underlying organic cause. If an underlying medical condition can be excluded, and there is no evidence to support a diagnosis of delirium or dementia, then the cause of psychosis may be functional. This is more likely if there is a family or personal history of mental illness.

Elderly onset RA: a diagnostic and therapeutic challenge

23 Jan 2020Registered users

Elderly onset rheumatoid arthritis (EORA) is defined as rheumatoid arthritis (RA) with age of first onset 65 years or over. It comprises an acute onset proximal or large joint arthritis with a prominent systemic syndrome characterised by constitutional symptoms and a higher ESR than in the younger patient with RA. Investigations should focus on trying to establish the cause and ruling out differential diagnoses. They should include inflammatory markers, serum uric acid, full blood count, rheumatoid factor/anti-CCP antibodies, and X-rays of the affected joint as well as the hands and feet. The possibility of malignancy should always be borne in mind. NICE recommends urgent referral of all suspected cases.

GPs are central to improving care of schizophrenia patients

20 Dec 2019Paid-up subscribers

Schizophrenia often runs a chronic course and is associated with considerable morbidity and mortality. While psychotic symptoms are the most obvious manifestations of the condition, negative symptoms (e.g. apathy and withdrawal) and cognitive symptoms (especially deficits in executive function) are often more disabling. It generally presents in late adolescence or early adulthood. Schizophrenia typically develops insidiously, potentially over several years. The GP is ideally placed to respond to family concerns, identify prodromal symptoms, screen for psychotic symptoms and initiate either a mental health review or active monitoring in primary care.

Early intervention key in first episode psychosis

20 Dec 2019Registered users

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.

More patients could benefit from referral for cardiac rehabilitation

25 Nov 2019Paid-up subscribers

Cardiac rehabilitation is a combination of medical and behavioural interventions designed to facilitate recovery and prevent future cardiovascular disease events. A cardiovascular prevention and rehabilitation programme (CPRP) is a critical element within the management pathway for most patients with heart disease and has a particularly strong evidence base for those with either symptomatic atherothrombotic vascular disease or heart failure. Following acute MI and/or coronary revascularisation, attending and completing a CPRP is associated with an absolute risk reduction in cardiovascular mortality from 10.4% to 7.6%.

Reducing stroke risk in patients with atrial fibrillation

25 Nov 2019Paid-up subscribers

Stroke is the most debilitating complication of atrial fibrillation (AF). AF-related strokes account for 20-25% of all strokes and are generally more severe and disabling and more likely to recur. Oral anticoagulation (OAC) remains the cornerstone of AF management with a clear prognostic benefit. It reduces stroke risk by two-thirds and mortality by a quarter. The decision to anticoagulate is taken irrespective of the pattern and duration of AF (paroxysmal, persistent or permanent). A large evidence base supports the use of OAC in men with a CHA2DS2-VASc score of 2 or more and women with a score of 3 or more. Hence, in the absence of absolute contraindications, OAC is strongly recommended.

Detecting obstructive sleep apnoea hypopnoea syndrome

24 Oct 2019Paid-up subscribers

Obstructive sleep apnoea hypopnoea syndrome (OSAHS) is characterised by repeated episodes of partial or complete collapse of the upper respiratory passages, mainly the oropharyngeal tract, during sleep. Obesity is the strongest risk factor for OSAHS; other risk factors include smoking, excessive drinking, sedatives and hypnotics. Habitual snoring, unrefreshing sleep and daytime somnolence suggests the possibility of OSAHS. When this is combined with a partner’s account of nocturnal apnoeas or snoring pauses the diagnosis becomes highly likely. However, negative screening results or the absence of clinical features by themselves should not be used to rule out OSAHS.

Improving COPD outcomes in primary care

24 Oct 2019Paid-up subscribers

Diagnosis of COPD is based on the presence of airflow obstruction after the administration of a bronchodilator i.e. post-bronchodilator spirometry. However, the National COPD Audit report for 2017-18 found that 59.5% of people hospitalised with a COPD exacerbation in England and Wales had no spirometry result available and in 12% of those who had undergone spirometry the test showed no airflow obstruction. Patients with COPD should be reviewed annually. It is advisable to repeat spirometry if there is a significant change in symptoms. It is important to determine objective measures of breathlessness (MRC dyspnoea score), quality of life (CAT questionnaire) and exacerbations (annual exacerbation and hospitalisation rate) as part of this review.


Special reports

Treating psychological trauma in the real world

23 Jan 2020Registered users

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.

Detecting and managing pulmonary hypertension

20 Dec 2019Registered users

Pulmonary hypertension (PH) is a haemodynamic state where the mean pulmonary artery pressure measured at cardiac catheterisation is 25 mmHg or more. Precapillary PH arises from increased resistance to blood flow in the pulmonary arterioles and postcapillary PH from elevated left atrial pressure. In postcapillary PH the cause is left heart disease whereas precapillary PH may be caused by any other form of PH. Patients develop symptoms only when the disease is advanced. Symptoms at presentation are non specific. Adults almost always present with breathlessness and may also complain of exercise-induced dizziness or syncope and angina. An echocardiogram is the best investigation to ascertain the probability of PH.

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.


Research reviews - by GPs with a special interest

Varicella exposure only partially protective against herpes zoster infection

23 Jan 2020Registered users

Household exposure to varicella infection only offers modest protection against herpes zoster infection in adults, a large self-controlled case series study has shown. Data were derived from the Clinical Practice Research Datalink (CPRD) which covers 9% of the UK population registered at more than 700 general practices. A total of 9,604 adults  with a diagnosis of herpes zoster, documented in primary care or hospital records, between 1997 and 2018, and who had lived with a child with a diagnosis of varicella were identified for the study.

Overweight adolescents consult more frequently for respiratory symptoms

23 Jan 2020Paid-up subscribers

Overweight teenagers are more likely to consult their GP for asthma, and other respiratory symptoms, than those of normal weight, a study from the Netherlands has found. A total of 617 children, aged 2 to 18 years, were recruited to a prospective cohort study from 71 GP practices across the country. Height and weight were measured at recruitment and other health and social data collated from questionnaires sent to patients/parents. Children with disabilities or conditions affecting their weight were excluded. Details of subsequent consultations were obtained from the medical records.

Most deaths in patients on methadone are not drug related

23 Jan 2020Paid-up subscribers

Non drug-related morbidities are the most common cause of death as methadone-treated opioid dependent patients age, a study from Scotland has found. The study authors used information from the Community Health Index and data on methadone prescriptions held within the Scottish National Prescribing Information System for 36,606 patients who had received one or more methadone prescriptions between 2009 and 2015.

Antihypertensive drugs most effective when taken at bedtime

20 Dec 2019Paid-up subscribers

Patients who took their blood pressure medication at bedtime had improved blood pressure control and lower risk of major cardiovascular disease events compared with those who took their drugs in the morning, a primary care study has shown.



Target oral anticoagulant therapy in AF patients at high risk

23 Jan 2020Registered users

Almost 50% of atrial fibrillation patients at very low thromboembolic risk are treated with oral anticoagulants contrary to guideline recommendations, a large global study has found.

Physical activity for 1 hour a week lowers risk of type 2 diabetes

20 Dec 2019Registered users

Being at least moderately physically active for an hour or more a week lowers the risk of type 2 diabetes compared with being inactive, results from the Whitehall ll prospective cohort study have shown. In those who developed diabetes any duration of moderate to vigorous activity reduced the risk of all-cause mortality. In those participants with diabetes who achieved the recommended levels of moderate or vigorous physical activity there was a reduction in cardiovascular mortality.


HASLAM's view

What makes your patient memorable?

23 Jan 2020Registered users

Even though I have not thought of these individuals for decades, one glance at the list of names and I can picture these patients and their homes with astonishing, almost Proustian clarity. Seeing these names, and experiencing the flashback of recognition that each engendered, reminds me what profoundly personal, human, and often unforgettable relationships we experience in general practice.

Never jump to conclusions about your patients

20 Dec 2019Registered users

If I had one overriding rule about GP consultations, it would probably be not to jump to conclusions.There are times when we feel absolutely certain that we know what is going on almost as soon as we collect the patient from the waiting room. I don’t know about you, but all too frequently I discovered that I was totally and embarrassingly wrong.


A hundred years ago

100 years ago: Improvements in public health 1917-1918

23 Jan 2020Registered users

WOMEN FORM an important element in the new electorate, and are already beginning to take an increasing interest in the administrative activities of local authorities in connection with maternity and child welfare. Medical services should be readily available for all needing them, and not confined, as at present, to insured persons, to persons under the poor law, and to mothers and children under local schemes and to children of school age under educational authorities. In other words, every person should have the right to command the best medical services throughout his or her life, including expert and consultative facilities, institutional treatment, and, of course nursing advantages.


A hundred and fifty years ago

150 years ago: Reduction of pitting from small-pox

23 Jan 2020Registered users

The terrible seaming and pitting of the face, neck and other exposed parts of the body so often consequent on bad attacks of small-pox are universally known. Reference, however, is seldom made to the total exemption of the scalp from marking of any kind, after even the severest form of this disease. It recently occurred to me, from watching a photographer using cotton-wool to shut out light in the process of ‘vignetting’ photographs, that this material, if applied to the face and neck of small-pox patients, might give a protecting influence somewhat similar to that afforded to the scalp by the hair, and thereby prevent or modify the subsequent pitting.