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

More patients could benefit from referral for cardiac rehabilitation

25 Nov 2019Registered users

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 2019Registered users

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.


Research reviews - by GPs with a special interest

Symptoms based approach to asthma may miss children at risk

25 Nov 2019Paid-up subscribers

Abnormal spirometry and FeNO results are common in children with asthma managed in primary care and relate poorly to symptom scores, a UK study has shown.

Is the incidence of diabetes declining?

25 Nov 2019Paid-up subscribers

A recent systematic review, published in the BMJ, has concluded that in countries where data is available the incidence of diabetes has been stable or falling since 2006.

Where do patients seek help for genitourinary symptoms?

25 Nov 2019Paid-up subscribers

The majority of patients with genitourinary (GU) symptoms do not attend sexual health clinic (SHCs), although many would consult their GP, an analysis of Natsal-3 survey data has shown. Natsal-3 is a probability sample survey of sexual behaviour involving 15,162 women and men in Britain aged 16-74 years.

Quitting smoking in pregnancy lowers risk of preterm birth

25 Nov 2019Paid-up subscribers

Smoking cessation in pregnant women is associated with a reduced risk of preterm birth, a large study from the United States has shown. Information was obtained from live birth certificates issued between 2011 and 2017 as part of the US National Vital Statistics System. Overall, 25,233,503 pregnant women who delivered live neonates and had data recorded on pre-pregnancy and trimester-specific cigarette smoking frequency were included in the analysis.


Special reports

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.

Epidermolysis bullosa requires lifelong monitoring

24 Oct 2019Paid-up subscribers

Epidermolysis bullosa (EB) arises from mutations within genes encoding for different proteins which contribute to the structural integrity of the epidermis and basement membrane zone. There are four major EB types: EB simplex (EBS), dystrophic EB (DEB), junctional EB (JEB) and Kindler syndrome. The main cutaneous features of inherited EB are mechanical fragility of the skin and formation of blisters and erosions with minimal trauma. The initial diagnosis of EB is based on the patient’s personal and family history and examination. Skin biopsies are taken from newly induced blisters to identify the level of skin cleavage which helps to determine the subtype.


CPD exercises associated with each issue

CPD exercise - November 2019

25 Nov 2019Paid-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:• Reducing stroke risk in patients with atrial fibrillation • More patients could benefit from referral for cardiac rehabilitation • Time to diagnosis key in improving lung cancer outcomes



Symptoms based approach to asthma may miss children at risk

25 Nov 2019Paid-up subscribers

Abnormal spirometry and FeNO results are common in children with asthma managed in primary care and relate poorly to symptom scores, a UK study has shown.

Childhood asthma peaks at the start of the school year

25 Sep 2019Registered users

Asthma exacerbations increase in children under 15 years, especially boys, when children return to school in September after the summer holidays, a UK study has found. The adjusted daily rate of GP in-hours asthma consultations in children was 2.5 to 3 times higher in the back to school excess period than in the baseline period.

Managing acute asthma in children

25 Jun 2018Paid-up subscribers

The BTS/SIGN guideline specifies that the accurate measurement of oxygen saturation is essential in the assessment of all children with acute wheezing. It recommends that oxygen saturation probes and monitors should be available for use by all healthcare professionals assessing acute asthma in primary care. It is important to use the appropriate size paediatric probe to ensure accuracy. Any patient who presents to the GP practice with any features of a moderate exacerbation should be referred to an emergency department for further assessment and monitoring. 



Adherence to anticoagulants suboptimal in patients with AF

25 Nov 2019Registered users

Both adherence to, and persistence with, oral anticoagulant (OAC) therapy in patients with atrial fibrillation (AF) is poor, a UK study has found. The authors analysed data from The Health Information Network database between 2011 and 2016. Adherence (taking drugs as prescribed) for all OACs was 55.2%. One-year persistence (continuation of drugs) for all OACs was 65.9%. Although the direct oral anticoagulants generally fared better than vitamin K antagonists both adherence and persistence were suboptimal for all OACs.

Suicide risk in doctors

24 Oct 2019

Male doctors have a lower suicide risk than the general male population, an analysis of English death registrations from 2011 to 2015 has found. However, the risk for female doctors is comparable with that of the general female population, although the male preponderance of suicide meant that there were in fact more than twice as many male as female doctor suicides. There are differences between specialties: compared with physicians, GPs are more than three times as likely to commit suicide.


HASLAM's view

Being given a diagnosis helps patients move on

25 Nov 2019Registered users

Having a name for a condition may help the patient come to terms with what is going on. Patients with Parkinson’s disease may curse its existence. However, having a name for their disease allows them to feel a sense of belonging with other sufferers, reducing isolation if not bringing cure.


A hundred and fifty years ago

150 years ago: Caesarean section for obstructed labour

25 Nov 2019

THE CAESAREAN OPERATION still remains an almost sacrificial one, reversing from necessity the teaching of British obstetrics; for the children thus preserved are comparatively many, the mothers disastrously few. Eighty-five per cent of deaths has been stated by an accurate writer as the probable results in our days. Probably as much, or more, may be learned from failure as from success. Here is such a failure from the obstetric ward of the Westminster Hospital. It can only be from the faithful record of cases and careful observance of facts that any better rules for guidance can be elicited. 

150 years ago: An indication for nitrite of amyl

24 Oct 2019

AT TWELVE O’CLOCK ON THE NIGHT of October 23, 1870, a woman begged I would instantly go and see her daughter, who, she said, ‘was in a dying state.’ On entering her bedroom, I saw the patient, a young married woman, half undressed, sitting on the corner of the bed and holding on to the bed-post. There was a dusky leaden hue about her face, neck, chest, and hands, and a cold damp sweat clung to her. Her body generally was cold, but her feet and legs were of an icy coldness. Her pulse could scarcely be felt. She was making violent efforts to breathe, and each inspiration was accompanied with marked recession of the supra-clavicular and the intercostal spaces. Loud sibilant rales with sonorous rhonchus could be heard over the greater part of the chest.  She tried to speak, but could only make faint gasps.


A hundred years ago

100 years ago: Anxiety: treatment by confession

25 Nov 2019

BY WHAT AMOUNTED TO the accidental cure of a profound anxiety neurosis, my attention was directed, or rather redirected, from the use of suggestion in treatment to the great importance of carefully examining the emotional history in this condition; and it appeared worth while to test, in a series of cases, the result of reducing the suggestive factor to a minimum, and to rely solely upon the simple expedient of going through each detail of the patient’s war history.