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 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:Care of the elderly

Diagnosing and treating mood disorders in older people

05 Feb 2019Registered users

Depression in older adults is common. Depressive symptoms may be part of a recurrent depressive disorder or experienced for the first time in later life as a result of changes in risk and resilience factors. There is an association between cerebrovascular pathology, vascular risk factors and depression. Physical illnesses, particularly those associated with frailty, are also important risk factors for depression. Depression has a distinct presentation in late life and low mood may not be the predominant presenting symptom. Older patients may present with physical symptoms, apathy, cognitive symptoms, agitation, retardation, fatigue or weight loss.

Managing arrhythmias in coronary artery disease

23 Jan 2019Registered users

A detailed history is essential in patients with coronary artery disease (CAD) to elucidate red flag symptoms necessitating urgent specialist assessment. Red flags include syncope and presyncope, particularly in patients with concomitant left ventricular systolic dysfunction. Palpitations with severe chest pain and breathlessness also warrant urgent assessment. Undiagnosed atrial fibrillation (AF) is common in older populations. LVEF of 35% or less is a predictor of increased risk of sudden death. All patients with CAD should therefore undergo assessment of LVEF, usually by transthoracic echocardiography.


Special reports

Investigating the underlying cause of erectile dysfunction

23 Jan 2019Registered users

Rates of erectile dysfunction (ED) increase with age, with an estimated 70% of men aged 70 affected to some extent. ED is a significant predictor of underlying cardiovascular disease. In addition to the onset and duration of symptoms, important points in the history to clarify are: how the patient defines their ED, whether they have ever had erectile function, whether morning erections are preserved, the context of ED and recent sexual history. Men should be asked about symptoms of hypogonadism such as loss of libido or low energy levels. Cardiovascular risk should be evaluated.

Improving outcomes for kidney transplantation

20 Dec 2018Registered users

Kidney transplantation is the optimum form of renal replacement therapy for suitable patients with end-stage renal disease. A successful transplant represents a much closer approximation to true renal replacement with excretion of waste products, regulation of electrolytes and other substances, than dialysis. The longer a recipient has been dialysis dependent before transplantation the poorer the outcome. Living donor transplantation is associated with better graft and patient survival than transplantation from a deceased donor. A genetic relationship with the recipient is not a prerequisite to becoming a living donor. Having a living donor offers the opportunity of pre-emptive transplant (i.e. avoidance of dialysis altogether).

Early recognition and prompt referral key in acute pancreatitis

22 Oct 2018Registered users

Early recognition, prompt referral to secondary care and close monitoring for complications is important in improving outcomes in acute pancreatitis. The diagnosis of acute pancreatitis should be considered in any patient presenting with abdominal pain. The most common pattern of pain is severe epigastric pain that radiates to the back, is exacerbated by movement, and is alleviated by sitting forwards.

GPs play a vital role in identifying and managing juvenile idiopathic arthritis

24 Sep 2018Registered users

Juvenile idiopathic arthritis (JIA) affects approximately 1-4 per 1,000 children under the age of 16. Girls are more commonly affected than boys. It is a heterogeneous condition, even within JIA categories, ranging from insidious arthritis affecting one to two joints to florid and life-threatening systemic arthritis. All patients with suspected JIA should be referred urgently to a specialist paediatric rheumatology team. Coordinated, multidisciplinary care within a specialist team is required to achieve optimal outcomes.

History taking the key to diagnosing food allergy in children

25 Jul 2018Registered users

Allergy to milk and egg are the two most prevalent food allergies in children. They are typically diagnosed in infancy and carry a good prognosis with the majority of cases resolving before the child reaches school age. Other allergies may present later in childhood and are more likely to persist. There is evidence of a causal link between early onset severe and widespread eczema that is unresponsive to moderate topical steroids and development of IgE mediated food allergy, in particular peanut allergy. The EAT study showed that infants who were weaned early and exposed to egg and peanut had a significant reduction in allergy to both foods.

Tailor BP targets to the older patient with hypertension

25 Jun 2018Paid-up subscribers

The prevalence of hypertension increases with age and older people are likely to benefit more from BP reduction because of their high baseline cardiovascular risk. However, older people are a very heterogeneous group and a single BP target will not be appropriate for all. Current evidence is based on ambulatory or healthy older populations as patients with significant complex conditions were not represented in randomised clinical trials. 

Diagnosis and management of migraine in primary care

22 May 2018Paid-up subscribers

The Landmark study, from 15 countries, reported that 94% of patients attending a GP with episodic disabling headache had migraine. Generally, an untreated migraine headache is moderate to severe and lasts for more than four hours. It is often pulsating, but patients may describe a feeling of ‘expanding pressure’ within the head. Most sufferers experience nausea although fewer patients actually vomit. Acute treatment should be taken as soon as a migraine headache starts to develop as later in the attack central sensitisation occurs and treatments become less effective.



Improving detection of non-melanoma skin cancer

05 Aug 2015Registered users

Basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) are clinically and pathologically distinct and both are locally invasive. However, while BCCs rarely metastasise, SCCs have the potential to do so especially when they arise on the ears or lips. Patients with one non-melanoma skin cancer (NMSC) have a higher risk of developing another NMSC and of malignant melanoma.

GPs have key role in early detection of melanoma

24 Jun 2013Registered users

Lesions which have a high index of suspicion for melanoma should not be removed in primary care. Patients should be referred urgently to secondary care with a history recording the duration of the lesion, change in size, colour, shape and symptoms. 


CPD exercises associated with each issue

CPD exercise - January 2019

23 Jan 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: • Diagnosing and treating mood disorders in older people • Managing arrhythmias in coronary artery disease • Investigating the underlying cause of erectile dysfunction


A hundred and fifty years ago

A 150 years ago: Treatment of pneumonia

23 Jan 2019Registered users

“Can it be seriously maintained that the low diet in the first case, that the loss of six ounces of blood in the second or the six leeches and other treatment in the two others, benefitted the pneumonia and hastened its resolution?”



Is exercise as effective as drug therapy in reducing systolic BP?

23 Jan 2019Registered users

The systolic blood pressure lowering effect of endurance or dynamic resistance exercise among hypertensive populations appeared similar to that of commonly used antihypertensive medications (ACE inhibitors, angiotensin-2 receptor blockers, beta-blockers and diuretics) in a network meta-analysis.


A hundred years ago

100 years ago: Old age and diet

23 Jan 2019Registered users

Great is youth – equally great is old age.
Great are the day and night.
Youth, large, lusty, loving – youth, full of grace, force, fascination.
Do you know that old age may come after you,
With equal grace, force, fascination?


Clinical reviews of research - by GPs with interest

Comparing incontinence rates following caesarean vs vaginal delivery of twins

23 Jan 2019Registered users

Urinary stress incontinence is more likely following vaginal than caesarean section (CS) delivery of twins, a multinational randomised controlled trial has shown.

What factors influence uptake of smoking in children?

23 Jan 2019Registered users

Living in a smoking household and having peers who smoke are key factors associated with children smoking, a cohort study has found. The investigators analysed data on 11,577 teenagers in the Millenium Cohort Study, a birth cohort of children born between September 2000 and January 2002 in the UK.

Type 1 diabetes in children is on the increase

23 Jan 2019Registered users

The incidence of childhood type 1 diabetes may double over the next two to three decades, findings from a multicentre European study suggest

Childhood trauma raises risk of drug misuse later on

23 Jan 2019Registered users

Individuals who suffer abuse as children are more likely to use marijuana or cocaine later in life, a study from the United States has found.


HASLAM's view

Do your patients notice what you wear?

23 Jan 2019Registered users

What do you wear when you are seeing patients? I have often thought that what doctors wear says a great deal about how they see themselves and that this impacts on the image they portray to their patients. The advice from the BMA is that doctors should ‘dress in a manner which is likely to inspire public confidence.’ What does that phrase mean to you?