Free Updates - Pearls

Galleri: a blood test that will revolutionise cancer diagnosis?

“Scientists have taken a step towards one of the biggest goals in medicine- a universal blood test for cancer.” (BBC news headline 19 January 2018). While this may still be a way off, the Galleri test, developed by a US firm, has shown promise and is being trialled in the UK. 

There are few cancers for which we have effective screening tests, and many cancers may only show signs or symptoms at a later stage when curative treatment options are less likely.  The tests we do have for screening can be unpleasant and intrusive, and some people find them unacceptable. The ‘holy grail’ would be to develop a non-invasive screening blood test for early-stage cancer across a variety of sites, with high levels of sensitivity and specificity. 

In this week’s Pearl we review the evidence behind this blood test and ask: 

• How effective is it when cancer is suspected? 

• How effective is it for population screening?  

Self-harm: creating a safety-plan

A recommendation of the 2022 NICE Guidelines on self-harm was that whilst we are waiting for support and assessment, we can help by encouraging the person to develop a safety-plan. 

“I just felt that by cutting myself I was getting a release from all the anger, the guilt, the stress of everything that was going on.” 

The UK has one of the highest rates of self-harm in Europe and whilst it can occur at any age, it is most common in young people and females.  

In many cases, the purpose of self-harm is to release overwhelming emotions and one of the recommendations of the 2022 NICE Guidelines on self-harm was that whilst we are waiting for CAMHS support and assessment, we can help by encouraging the young person to develop a safety-plan. 

Would you feel confident to do this? As a team at Red Whale, some of us weren’t sure.  In this week’s Pearl we share a WhaleArt on how to create a safety-plan or you can read more in this microskill article below

Acute retention: sort the catheter… then think: why?

Acute urinary retention is much more common in men than women. The commonest cause is obstruction due to benign prostatic hypertrophy, but it can also be triggered by infection, drugs or, on occasion, cancers causing extrinsic compression. 

 A Danish study showed that those who go into acute retention are at an increased risk of being diagnosed with genitourinary cancers in the following 12 months.  

The risks are: 

• Prostate cancer: absolute risk increase almost 7% at 12 months. 

• Bladder cancer: absolute risk increase almost 2% at 12 months. 

• In women, there was also a small increased risk of bladder cancer (roughly half that of men) and gynaecological cancers (<1% absolute risk increase at 12 months, mainly ovarian and endometrial cancers). 

• In men and women, there was a small increased risk of colorectal and neurological cancer in the 3 months after admission (absolute risk increase at 12 months 0.6 and 0.1%). 

So, next time you see someone in acute retention, yes, get that catheter sorted and treat the underling BPH/infection, etc., but also think about the possibility of cancer.  

Don’t assume they have cancer (the increased risk wasn’t that remarkable!), but do think about whether they had any symptoms prior to this (e.g. haematuria, bloating), and you may want to look for microscopic haematuria once the catheter is out. And…have your antennae out if they present with any genitourinary symptoms in the months afterwards! 

For a thorough MOT on men’s health, why not join Ayo on the Red Whale sofa on Thursday 16 November for a half-day Men’s Health Together? Or watch on demand any time. And remember, if you are a Red Whale Unlimited member, this is all included.  

Preventing breast cancer: what’s our role?

Anastrozole: Thousands to be offered drug to prevent breast cancer (BBC, 8 November 2023). And the phones start ringing…This is about the MHRA now licensing anastrozole for primary prevention of breast cancer in postmenopausal women at moderate to high risk.

It has been recommended for off-licence use in this context for quite some time.  So, this news has to be read in the context of the whole NICE guideline on the assessment of genetic risk for breast cancer.

Here are the headlines:

• 1 in 5 cases of breast cancer occur in women with a significant family history. 
• Our role in primary care is to: 
  • Take a first and second-degree family history to identify people at high or moderate risk of breast cancer when they present with breast symptoms or concerns.
  • Refer them to secondary care for genetic assessment and a management plan, which may include additional screening, preventative medication (usually tamoxifen or anastrozole) and/or risk-reduction surgery. 
  • Prescribe preventative medication if indicated on advice of a specialist.

In this week’s Pearl, we share our article on Breast cancer: genetic risk, where we explore how to assess risk, the evidence for preventative medication and some of the side-effects people taking it may experience.

It may make it easier to answer some of those calls…

Click here to read more.

Healthy ageing: adding quality to years?

In the end, it’s not the years in your life that count. It’s the life in your years.” Abraham Lincoln  This week’s Pearl is one for reflection with a cuppa – it’s about a 10-minute read!

• What does ‘healthy ageing’ look like? 

• What are the 3 trajectories of ageing? 

• How can we work as a primary care team to promote the basics that increase the chance of healthier ageing?  

To consider the big picture of care for our older community, why not join Sue on the Red Whale sofa for the Older People and Frailty half-day course on Thursday 9 November? Or watch any time on demand. And remember, if you are a Red Whale Unlimited member, this is all included.  

Common, easily missed and affects 10% of females of reproductive age…

Did you guess? Endometriosis is the subject of this week’s Pearl.  Read more in our Pearl; including options for first-line management, reasons for referral and surgery, and the impact of menopause on endometriosis.

Here are some headlines:  

• We can suspect endometriosis based on symptoms and signs: pelvic pain, dysmenorrhoea, cyclical gastrointestinal/urinary symptoms, deep dyspareunia or infertility in association with these symptoms.

Remember:  

• A normal examination does not exclude endometriosis.  

• Transvaginal ultrasound may detect endometriosis but, if normal, does not exclude it.  

• If ultrasound is normal AND the person is not trying to conceive, we should offer medical management. 

• We should refer for diagnostic laparoscopy if imaging was negative AND first-line medical management has been unsuccessful OR if fertility is a concern. 

And for an update on all things women’s health, why not join Helen and Lucy on the Red Whale sofa on Thursday 2 November for our live-hosted Women’s Health Together? Or watch any time on demand. And remember, if you are a Red Whale Unlimited member, this is all included.  

COVID…there’s a lot of it around…again!

In this week’s Pearl, a delegate request, we summarise the current state of play with antiviral treatments for COVID.  We need to know about this so that we can signpost appropriate patients to access treatment – whatever our local route.  

Our article will cover who is eligible, what should be prescribed and the evidence base. 

Here are some headlines: 

• People at highest risk of becoming seriously ill from COVID-19 are eligible for antivirals in some circumstances.  

• Paxlovid (nirmatrelvir plus ritonavir) is the first-line antiviral therapy.  

• Prescribing antivirals has been decentralised since June 2023: this means that, in some places, it falls to individual clinicians; in others, it may be organised by PCN groups. 

• In Scotland, patients contact their health board.  

• In Wales, they are prescribed by 111.  

“I’m struggling…”

GP burnout has been in the news again this week, and this will not come as a surprise to most of us working in primary care. And it can affect any role – not just GPs.  This week we are sharing a Pearl that can hopefully help however you're feeling at the moment. 

One GP bravely shared their story about burnout with the BBC. This may have triggered some of us to identify that we, or one or more of our colleagues (any role working in frontline primary care!), may be struggling too. 

Burnout is defined as “chronic workplace stress that has not been successfully managed”. As we work in a system that is currently struggling to stand on its feet, “successfully managing workplace stress” is extremely difficult at practice level. 

We can’t solve this system failure. But, wherever you are at, we wanted to offer you some support in this week’s Pearl.

I’m not OK… 

You are not alone. Please seek help. Our article Sources of support for health professionals has contact details for sources of support, including the NHS Practitioner Health Programme: 

I’m OK, but I am worried a colleague might be experiencing burnout… 

You can read more about this in Burnout in health professionals, and it might help you start that difficult conversation with your colleague: 

I’m OK, but I am concerned I’m becoming less OK… 

You might find our article on Self-compassion: the three-circles model a helpful framework for identifying areas you might be able to rebalance to help you sustain you. 

HRT for primary prevention?

About 25% of menopausal-age women have no symptoms and so do not require HRT to treat vasomotor or other hormone-related issues. However, they may be influenced by media messages suggesting that HRT could be used to prevent certain chronic diseases. Read more in this week's Pearl!

However, they may be influenced by media messages suggesting that HRT could be used to prevent certain chronic diseases (such as dementia, osteoporosis and cardiovascular disease), especially if started early in the menopause transition.

Sometimes, they seek our advice about whether they should take HRT to reduce their risk of developing health problems in later life, particularly if they have first-hand experience of supporting a relative with a chronic disease.

 So, should we  agree to prescribe HRT to prevent disease?

Click on the PDF to read more in this week’s Pearl.

And, if you would like to learn more or brush-up on your menopause skills, why not join Helen Barnes and Lucy Cox on the Red Whale sofa for the half-day Menopause Course on Wednesday 11 October at 09:30. Or, if you prefer, you can watch on demand when it suits you.

Molluscum contagiosum…a nuisance but not a spell!

Molluscum contagiosum is my all-time favourite condition to diagnose in children – it just sounds magical! But it is a bit of a nuisance. 

Here are the headlines: 

• It is a viral skin infection, more common in children, particularly those with eczema. 

• The lesions are pearly, small, round papules with a central punctum. They generally cause no symptoms. 

• It is usually self-limiting (in 6–18 months!); no treatment has been found to offer significant benefit over placebo.  

• It can, however, exacerbate pre-existing eczema, and this does need to be managed! 

• Extensive molluscum, particularly in adults, should prompt us to think about immunosuppression. 

Want to learn more, including who needs referral, what to do with anogenital lesions and possible new treatments? 

My eyelids are all sticky in the morning…the drops I bought aren’t helping!

This week’s Pearl is all about blepharitis. It is pretty common and is responsible for about 5% of primary care eye consultations – so, worth a reminder!  

Here are the headlines: 

• Blepharitis is chronic inflammation of the eyelids and is usually bilateral. 

• Mean age of onset is 50y.  

• It is associated with dry eyes, seborrhoeic dermatitis and acne rosacea. 

• Lid hygiene, including warm compresses and ‘eyelid scrubs’, is the mainstay of treatment.  

Want to learn more, including making the diagnosis, whether a slit lamp examination is really necessary and the role of topical steroids (hint: not in primary care!)? 

Tics and Tourette’s syndrome: spotting them in primary care

Lewis Capaldi brought Tourette’s into the public eye during his performance at Glastonbury this summer when he authentically shared the challenges he has been experiencing since being diagnosed. He has been keen to dispel myths that Tourette’s is all about swearing uncontrollably.  

Here are the headlines: 

• Tics are pretty common in childhood, with up to 20% of children being affected at some point. For most, these tics are transient.  

Tics are involuntary, sudden, recurrent non-rhythmic movements. They can be:  

• Motor or verbal.  

• Simple (involving a single muscle group) or complex (resembling fully formed gestures. 

• Tourette’s can be diagnosed when there are at least 2 motor and 1 vocal/phonic tic present for at least 12 months.  

• Coprolalia (swearing) and copropraxia (rude gestures) occur in only about 10% of cases. 

• If we suspect this in primary care, we should refer, usually to CAMHS, although local pathways may vary.  

Want to learn more, including what constitutes a tic, common comorbidities and how Tourette’s is managed?  

Click on the PDF button to read this week’s Pearl!

GLP-1 mimetics shortages: tackling drug swaps

The GLP-1 mimetics (particularly semaglutide) are rarely out of the news at the moment: approval by NICE for obesity; concerns about celebrity misuse; claims by the manufacturers of impressive cardiovascular benefits (not yet published in a peer reviewed journal); and, most recently, supply issues for people with type 2 diabetes. They certainly are headline grabbers! 

This has brought several challenges for us in primary care. The shortages of the injectable form licensed for type 2 diabetes are not expected to resolve until at least 2024. 

This week’s Pearl focuses on how we can best manage medications for type 2 diabetics affected by this shortage. 

Headlines include:  

• Only prescribing GLP-1s for licensed indications.  

• Avoiding initiating them for type 2 diabetes right now. 

• Stopping them if they are not achieving the desired effect. 

• When there are local shortages, prioritising review of those with poorest control. 

• Personalising medication reviews and swaps based on the individual and HbA1c. 

Read our Pearl to find out more.