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.



Prompt investigation improves outcomes for kidney cancer

22 Feb 2018Registered users

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 2018Registered users

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.


Special reports

Diagnosis and management of oesophageal cancer

22 Feb 2018Registered users

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 2018Registered users

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.


Clinical reviews of research - by GPs with interest

Anticoagulants underused in older heart failure patients with AF

27 Feb 2018Registered users

Overestimation of risk of bleeding leads to underuse of oral anticoagulants in frail elderly heart failure patients with atrial fibrillation (AF) despite their increased risk of stroke, a study in Heart has concluded.

Poor glycaemic control associated with accelerated cognitive decline

27 Feb 2018Registered users

Rates of cognitive decline were greater in patients with diabetes and prediabetes compared with those who were normoglycaemic, in the English Longitudinal Study of Ageing (ELSA).

Maternal sleeping position may raise the risk of late stillbirth

22 Feb 2018Registered users

Pregnant women who went to sleep in a supine position had a two-fold increased risk of late stillbirth, a UK study has shown.

Assessing suicide and self-harm risk in adolescents

22 Feb 2018Registered users

The incidence of suicide in adolescent boys is more than twice that among adolescent girls, whereas non-fatal self-harm is much more common in girls than boys, an English retrospective database study has found.


Cardiovascular medicine

Anticoagulants underused in older heart failure patients with AF

27 Feb 2018Registered users

Overestimation of risk of bleeding leads to underuse of oral anticoagulants in frail elderly heart failure patients with atrial fibrillation (AF) despite their increased risk of stroke, a study in Heart has concluded.

Improving uptake of cardiac rehabilitation

23 Oct 2017Registered users

Data from the National Audit of Cardiac Rehabilitation show that 50% of eligible MI, PCI, and CABG patients do attend cardiac rehabilitation and that figure continues to rise, but the rates for stable angina and heart failure remain low. There is evidence that programmes which have a basis in psychoeducation (goal setting, self-monitoring, relapse prevention) are more likely to achieve long-term behaviour change than those based simply on delivering a fixed agenda of exercise and education. A recent Cochrane review of exercise-based cardiac rehabilitation continues to show the benefit of exercise prescription in terms of cardiovascular mortality, hospital readmission rates, and quality of life.

Timely diagnosis of heart failure can improve prognosis

28 Jul 2017Registered users

Heart failure is a common, complex clinical syndrome resulting from the impaired ability of the heart to cope with the metabolic needs of the body, leading to breathlessness, fatigue and fluid retention. It is a progressive disease characterised by high levels of morbidity and mortality. Measuring plasma levels of natriuretic peptides is recommended for ruling out heart failure, as patients with normal levels are unlikely to have heart failure. An echocardiogram is indicated if the natriuretic peptides are elevated, or natriuretic peptide testing is not available.


A hundred years ago

Treatment of confirmed neurasthenia pura

22 Feb 2018Registered users

THE AVERAGE GENERAL PRACTITIONER is wont to regard electricity as a faddist treatment which he would fain relegate to the domain of medical quackery. The following case, one of many, may be quoted to illustrate the high therapeutic virtues of D’Arsonvalization in neurasthenia pura, inspite of the lifelong and progressive existence of emotive aberration, and the predominance of cerebral symptoms.


A hundred and fifty years ago

Paralysis agitans senilis cured by electricity

22 Feb 2018Registered users

WHILE OCCUPIED some few days ago in preparing an electromagnetic machine for application to a patient, an old servant (upwards of 80 years), who had long been subject to violent spasmodic tremblings of both arms, chanced to enter the room. More, in the spirit of levity than either philanthropy or philosophy, I asked her to take hold of the electrodes of the machine, at the same time pressing the bundle of soft wires some distance into the centre of the helix, so as to give a pretty sharp shock.



Smoking just one cigarette a day raises risk of CHD and stroke

22 Feb 2018Registered users

Smoking one cigarette per day carries a risk for cardiovascular disease of around half that of those who smoke 20 per day, a systematic review and meta-analysis has found.

Should sertraline be used in CKD patients with depression?

23 Jan 2018Registered users

Sertraline is ineffective in patients with chronic kidney disease (CKD) and depression, a randomised controlled trial, from the USA, has found. This study suggests that the prescription of sertraline, and indeed any SSRI, to stage 3b-5 CKD patients with depression can no longer be justified. CBT is probably the best option and there is some evidence of its efficacy in end-stage CKD patients.


HASLAM's view

The patients that never come back

22 Feb 2018Registered users

'None of my patients has ever returned for further therapy, and so I mark that down as satisfaction and success,' the orthopaedic surgeon told me.


CPD exercises associated with each issue

CPD exercise - February 2018

22 Feb 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: • Visible and non-visible haematuria may herald serious disease • Prompt investigation improves outcomes for kidney cancer • Diagnosis and management of oesophageal cancer


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]