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

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.

GPs are central to improving care of schizophrenia patients

20 Dec 2019Registered users

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.

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

Detecting and managing pulmonary hypertension

20 Dec 2019

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.


CPD exercises associated with each issue

CPD exercise - December 2019

20 Dec 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: • Early intervention key in first episode psychosis • GPs are central to improving care of schizophrenia patients • Detecting and managing pulmonary hypertension


Research reviews - by GPs with a special interest

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.

Automated cough sound analysis shows promise as a diagnostic tool

20 Dec 2019Paid-up subscribers

Analysis of cough sounds captured on a smartphone can potentially be used to help diagnose common respiratory conditions in children, a study from Western Australia has shown. The study authors conclude: ‘We have demonstrated that automated cough analysis delivers good diagnostic accuracy in detecting common childhood respiratory diseases including pneumonia, RAD, croup, bronchiolitis, upper and lower respiratory tract disorders. It can be used as a diagnostic aid for childhood respiratory disorders.’

Tailor smoking cessation advice to the patient

20 Dec 2019Paid-up subscribers

Effectiveness of smoking cessation aids varies between different types of smokers, a survey-based UK study has found. The data presented in this large, representative sample may provide useful information for GPs and other treatment providers in tailoring quit smoking advice to individual patients.

Symptoms based approach to asthma may miss children at risk

25 Nov 2019Registered users

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.



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.

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.


HASLAM's view

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 and fifty years ago

150 years ago: Hysterical paraplegia in a patient suffering from epileptic mania

20 Dec 2019Registered users

E.S, A GIRL OF 16 YEARS of age, suffering from epileptic mania, and never having menstruated, was admitted into the Brookwood Asylum in October 1868, being unable to use either of her legs, and having in consequence to be carried into the ward on her arrival. A few days after her admission the use of Browning’s electro-magnetic machine was commenced About the end of December she was enabled to crawl about, and employ herself a little in cleaning the floors of the infirmary in which she was placed. She gradually improved, and during the second week in March she had her first catamenial period. In the beginning of April she suddenly discarded her crutches, which she had used for two or three months; and at the ball given to the patients the following week, danced several times, appearing to have quite recovered both sensation and motion. 

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. 


A hundred years ago

100 years ago: Syphonage method in the treatment of severe injury of the bladder

20 Dec 2019Registered users

TO APPRECIATE TO THE FULL his recovery, a few observations on his condition on arrival are noteworthy. He was a most pitiable sight. The stretcher on which he had travelled was saturated with urine, which, during the journey from France, had been extravasating over his abdomen from the still open bladder wound. Thin and emaciated, the boy was obviously very ill from septic absorption, and the want of mental as well as of bodily rest was aggravating the miseries of his condition. On examination of the abdomen, there was an unhealthy, lacerated, saucer-like wound about 4 inches in diameter, just above the symphysis pubis, and in its lower quadrant was an opening into the bladder, through which thick, foul-smelling urine was flowing over the abdomen. The skin of the abdomen, especially around the wound area, was excoriated and septic from the constant chafing of urine-sodden masses of dressing. The catheter had been given up at an early date. The urine itself was thick with pus, phosphates, and mucus.