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COVID-19 Update: Supporting our rheumatology patients

Read the latest version of our COVID-19 Update: Supporting our rheumatology patients FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

For instructions on how to access our Pearls on GPCPD click here to watch a short instruction video. Alternatively, you can read full instructions by clicking the PDF button. 

COVID-19 Update: Remote Consulting Domestic Abuse

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COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

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COVID-19 Update: The Role of Primary Care in Care Homes

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COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

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COVID-19 Update: Supporting our patients during Ramandan

Read the latest version of our COVID-19 Update: Supporting our patients during Ramandan FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

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COVID-19 Update: COPD and Asthma during the COVID-19 pandemic

Read the latest version of our COVID-19 Update: COPD and Asthma during the COVID-19 pandemic FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

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COVID-19 Update: Coronavirus COVID-19

Read the latest version of our COVID-19 Update: Coronavirus COVID-19 FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

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COVID-19: symptom control (including end-of-life care)

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COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

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COVID-19: End of Life Care Discussions

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COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

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COVID-19 Update: Standard Operating Procedures

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COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

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COVID-19 Update: Death in the community

Read the latest version of our COVID-19 Update: Death in the community FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

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COVID-19 Update: Clinical assessment and management in the community

Read the latest version of our COVID-19 Update: Clinical assessment and management in the community FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

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COVID-19: Workload prioritisation

Read the latest version of our COVID-19 Update: Workload prioritisation FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

For instructions on how to access our Pearls on GPCPD click here to watch a short instruction video. Alternatively, you can read full instructions by clicking the PDF button. 

COVID-19: Drug and disease pitfalls to avoid

Read the latest version of our COVID-19: Drug and disease pitfalls to avoid FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

For instructions on how to access our Pearls on GPCPD click here to watch a short instruction video. Alternatively, you can read full instructions by clicking the PDF button. 

COVID-19: Remote contraception and abortion advice

Read the latest version of our COVID-19: Remote contraception and abortion advice FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

For instructions on how to access our Pearls on GPCPD click here to watch a short instruction video. Alternatively, you can read full instructions by clicking the PDF button. 

COVID-19: Remote Consulting Survival Guide

Read the latest version of our COVID-19 Update: Remote Consulting Guide FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

For instructions on how to access our Pearls on GPCPD click here to watch a short instruction video. Alternatively, you can read full instructions by clicking the PDF button. 

Join us for a FREE webinar on surviving remote consulting. Join Dr Osman Bhatti, Red Whale presenter and self-confessed digital enthusiast, and Dr Hussain Gandhi (Dr Gandalf of eGPlearning), who will be appropriately socially distancing rather than sat together on the Red Whale sofa.

CLICK link to sign up for the webinar. https://www.gp-update.co.uk/webinars/OWREM250320

COVID-19: An emotional and psychological survival guide

Read the latest version of our COVID-19:  An emotional and psychological survival guide FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

For instructions on how to access our Pearls on GPCPD click here to watch a short instruction video. Alternatively, you can read full instructions by clicking the PDF button. 

Are there any high-risk features that should alert us to consider bladder or renal cancer?

05 Mar 2020

Regarding the risk of primary care symptoms for all urological cancers, the only high-risk feature in primary care is visible haematuria.

More info PDF

Are there any high-risk features that should alert us to consider bladder or renal cancer?

Regarding the risk of primary care symptoms for all urological cancers, the only high-risk feature in primary care is visible haematuria.

Having said this, not all patients with bladder or renal cancer experience visible haematuria. So, how do we determine who we should refer for further investigation? And when might non-visible haematuria be significant?

We will look closely at issues around prostate cancer in next week’s webinar being run in association with Macmillan Cancer Support. But meanwhile, as a urological cancer taster…..

There are 10,000 new cases of bladder cancer (the incidence is decreasing) and nearly 13,000 new cases of kidney cancer (renal cell carcinoma) per year in the UK. Around 50% of people survive these cancers for 10 or more years.

It is estimated that about one-third of cases of bladder and renal cancer are preventable. The major risk factors for bladder and kidney cancers include:

  • Smoking.
  • Overweight and obesity.
  • Occupational exposure to industrial chemicals, e.g. aromatic amines found in the dye, textile, pesticide and rubber industries (bladder cancer only).
  • Family history of an affected first-degree relative.
  • Radiation exposure, e.g. pelvic irradiation for other cancers.
  • Schistosomiasis for bladder cancer (rare in UK population).

Regarding the risk of primary care symptoms for all urological cancers, the only high-risk feature in primary care was visible haematuria, with a PPV of 5.1% in a BJGP study.

Having said this, not all patients with bladder or renal cancer experience visible haematuria, so, if investigations are restricted to this group alone, some diagnoses will inevitably be delayed. The low PPV of other symptoms, even in clusters, makes selecting other groups for urgent investigation difficult.

For non-visible haematuria in those over 60y, the PPV is >3 only if also presenting with dysuria or with a raised WBC count.

Antiplatelets and anticoagulants may contribute to haematuria, but for those with non-visible haematuria on these medications, 10% will have pathology (this is in line with the background population). So, we should not attribute haematuria to these drugs without investigating.

Women experience more delays in diagnosis of bladder cancer than men.

Remember, bladder cancer is an industrial disease for a small proportion of patients, and they may be entitled to compensation.

Also remember to store test sticks in the correct container with the lid closed – prolonged exposure to air or damp may give a false positive result. Check the guidance for the brand you use in your surgery, and check expiry dates!

Click on the PDF to see our summary of the NICE guidance, and BMJ and BJGP articles, on bladder and renal cancer.

What do we need to consider when we are asked for a prescription to postpone periods?

27 Feb 2020

Partial metabolism of norethisterone to ethinyloestadiol means that we should be thinking carefully when asked to prescribe norethisterone in order to postpone periods. What is the risk, and what are the main contraindications?

More info PDF

What do we need to consider when we are asked for a prescription to postpone periods?

Partial metabolism of norethisterone to ethinyloestadiol means that we should be thinking carefully when asked to prescribe norethisterone in order to postpone periods. What is the risk, and what are the main contraindications?

Given the sheer array of problems women can have with their periods (which we will be covering in detail in our Deep Dive webinar), it isn’t surprising that sometimes we get requests to postpone menstruation. These requests may relate to holiday plans or be for other reasons.

Discussions about the length of the holiday and prescribing the appropriate quantity of norethisterone take a short amount of time. 

We might even prescribe on request without such a discussion. But should we be thinking this through more carefully?

MHRA guidance highlights important contraindications. Partial metabolism to ethinyloestadiol means that, at therapeutic doses, we need to be thinking about VTE risk and assessing this as we would for combined hormonal preparations.

Click on the PDF to see our summary of a J Fam Plann Reprod Health Care review article and MHRA guidance relevant to prescribing norethisterone in order to postpone periods.

Tight foreskins – what can we do short of circumcision?

18 Feb 2020

Phimosis may be simply physiological and cause no problems. It may be secondary to an underlying skin disease. So, what do we need to look for, and what are the treatment options?

More info PDF

Tight foreskins – what can we do short of circumcision?

Phimosis may be simply physiological and cause no problems. It may be secondary to an underlying skin disease. So, what do we need to look for, and what are the treatment options?

Phimosis may be physiological. It may be primary. It may be secondary to an underlying skin disorder. Whichever of these, and whether child or adult, your patient is likely to feel embarrassed about discussing the problem and awkward about physical examination.

If asymptomatic, it requires no treatment. But if it does require treatment, what should we offer? When might topical corticosteroids be appropriate and when should we refer?

Click on the PDF to see our summary of a BMJ review on phimosis and the British Association of Paediatric Urologists' statement on circumcision.

There are many other health issues that men might feel embarrassed or awkward about discussing with us! We too might feel uncertain about these issues.


Click to join us for our Deep Dive webinar: Men's Health Laid Bare.

We'll be coming to you live on Thursday 27 February 2020 at 8pm. Do you feel muddled by men's health? Perplexed by prostatitis? Bamboozled by testosterone bloods? We will tackle the issues of erectile dysfunction, the male menopause and much more!

We will cover:

  • Erectile dysfunction, including important initial investigations.
  • The role of PSA testing in these men.
  • Treatment and drug interations.
  • Testosterone deficiency - diagnosis, investigation and monitoring.
  • Quinolone prescribing following the NICE guidance on acute prostatitis released in 2018.

The format:

There will be an opportunity to take part in interactive polls, download some fantastic resources to support your practice, and ask our team your burning questions.

Join us live on Thursday 27 February 2020 at 8pm and then on demand from the next day.

An adrenal incidentaloma is noted on the scan report - what do you do next?

13 Feb 2020

The CTKUB scan showed a single small renal stone. However, that wasn't the only thing on the scan result: it reports a small lesion in the right adrenal gland, but unfortunately doesn't give you any advice on what to do next! So, what do you do?

More info PDF

An adrenal incidentaloma is noted on the scan report - what do you do next?

The CTKUB scan showed a single small renal stone. However, that wasn't the only thing on the scan result: it reports a small lesion in the right adrenal gland, but unfortunately doesn't give you any advice on what to do next! So, what do you do?

You request a CTKUB. By the time you get the result, the patient has already rung to tell you that have "passed the little blighter", and indeed the scan showed a single small stone that was likely to come out on its own. However, that wasn't the only thing on the scan result: it reports a small lesion in the right adrenal gland, but unfortunately doesn't give you any advice on what to do next! So what do you do?

  • All adrenal incidentlomas need referring to endocrinology but take a history first: features such as hypertension, flushes or Cushingoid appearance that are pertinent to the referral may affect how quickly the patient is seen.
  • Most (85%) are benign and produce no hormones.
  • Lesions<4cm that are lipid-rich and produce no hormones are often left alone and need no ongoing monitoring, but that is a decision for the endocrinologists: our job is to refer!

Click on PDF to see our summary of 2018 BMJ Clinical Update on adrenal incidentalomas.

There are several options for the treatment of actinic keratosis, but which is the best?

05 Feb 2020

The options for treatment of actinic keratosis include topical and physical treatments, depending on the grading and location of the lesions. In January 2020, the marketing authorisation for ingenol was suspended due to risk of skin malignancy.

More info PDF

There are several options for the treatment of actinic keratosis, but which is the best?

The options for treatment of actinic keratosis include topical and physical treatments, depending on the grading and location of the lesions. In January 2020, the marketing authorisation for ingenol was suspended due to risk of skin malignancy.

We are asked to stop prescribing ingenol and consider other treatment options, as appropriate. So, what is the best treatment?

There are several options for the treatment of actinic keratosis, including topical and physical treatments, depending on the grading and location of the lesions. But what is the best treatment?

A 2019 NEJM article looked at the effectiveness of four treatments that are field-directed: 5% fluorouracil cream, 5% imiquimod cream, photodynamic therapy and 0.015% ingenol mebutate gel.

5% fluorouracil cream was shown to be the best – and is the cheapest!

Is fluorouracil the first-line agent in your area?

Note that in January 2020, the marketing authorisation for ingenol was suspended due to risk of skin malignancy. We are asked to stop prescribing ingenol and consider other treatment options, as appropriate. We are also asked to advise patients to be vigilant for any skin lesions developing within the treatment area, and to seek medical advice promptly should any occur.

Has your local formulary/prescribing guideline been updated to reflect this change?

Click on the PDF to see our summary of a DTB review, a 2019 NEJM article, and the MHRA advisory on actinic keratosis and its treatment.

How confident do you feel when it comes to treating gout?

30 Jan 2020

When we are now encouraged to start disease-modifying treatment following a first attack of gout, how can we be confident enough in our diagnosis to recommend urate-lowering treatment? 

More info PDF

How confident do you feel when it comes to treating gout?

When we are now encouraged to start disease-modifying treatment following a first attack of gout, how can we be confident enough in our diagnosis to recommend urate-lowering treatment? 

You might be confident based on your clinical judgement to start a course of treatment for an attack of gout, but are you confident enough to be recommending disease-modifying treatment with a first attack? When might diagnostic tests be indicated, and, importantly, does primary care scoring system that does not require aspiration perform better than clinical judgement alone?
 

Pete, age 58y, limps into your consulting room. “My big toe is killing me”, he says. “The same thing happened about a year ago but it went away with taking ibuprofen for a few days. Now I think this might be gout.”

Pete has hypertension which is controlled with ramipril. His right first MTP joint is red, swollen, warm and painful to move.

You feel confident, based on clinical assessment, to manage this episode as an attack of gout, but recall reading that we should start urate-lowering treatment after a first attack of gout. Are you confident enough to recommend disease-modifying treatment for Pete?

And what if you were less certain about the diagnosis, for example if it were his ankle affected rather than MTP joint? When do you need to consider diagnostic tests? Should you be considering joint aspiration?

For a typical attack, clinical features have a high likelihood ratio of being correct. However, a scoring system can improve accuracy of diagnosis. Pete will want to know that you are confident about your diagnosis if you are suggesting that he needs disease-modifying treatment. There is a primary care scoring system that does not require aspiration and that performs better than clinical judgement alone.

Click below to see our summary of the 2017 British Society of Rheumatology guideline on gout (which is endorsed by NICE) along with numerous other recent articles looking at diagnosis, investigation and management.

Are prophylactic antibiotics effective for recurrent UTI in the elderly?

23 Jan 2020

A study looking at patients over the age of 65y with a history of recurrent UTI found that use of prophylactic antibiotics reduced the risk of recurrent UTI by 51% in women and 43% in men. But there is more to this story!

More info PDF

Are prophylactic antibiotics effective for recurrent UTI in the elderly?

A study looking at patients over the age of 65y with a history of recurrent UTI found that use of prophylactic antibiotics reduced the risk of recurrent UTI by 51% in women and 43% in men. But there is more to this story!

 

A study looking at patients over the age of 65y with a history of recurrent UTI found that use of prophylactic antibiotics reduced the risk of recurrent UTI by 51% in women and 43% in men. This had a corresponding effect of a 22% reduction in UTI-related hospital admission in men, but this was not seen in women. 

Of those who did get antibiotics, more than 50% took them for over 2 years!

This study did not look at antibiotic-related adverse events or at rates of resistant bacteria in urine, and the data is reliant on accurate read-coding of UTI diagnoses in primary care, so we cannot comment on the possible harms of prophylactic antibiotics for recurrent UTI in the elderly from these results.

So, food for thought when you next discuss recurrent UTIs with an older person, or do theo=ir medication review and see they have been on the antibiotic for 2 years!

Click below to see our summary of 2018 NICE guideance and articles from the BMJ and Age and Aging on recurrent UTIs.

Understanding the different roles in the ARRS

15 Jan 2020

Like it or loathe it, the PCN seems here to stay, though whether primary care stays with DES is a different matter altogether!

More info PDF

Understanding the different roles in the ARRS

Like it or loathe it, the PCN seems here to stay, though whether primary care stays with DES is a different matter altogether!

One of the opportunities of the DES is the potential to integrate new roles into primary care to help solve some of the key challenges that many of us are facing, particularly shortage of GPs and increasing patient demand. This is also known as the Additional Role Reimbursement Scheme or ARRS.

Regardless of the outcome of the DES specification consultation and our individual practice choices about whether to participate, multidisciplinary primary care may be a good pragmatic option for many of our teams.

But this represents a big change and, like all change, if managed badly, it will cause more stress, disillusionment and wasted time. So, we need some pointers to make it work.

We are offering some resources and support to make this as easy as possible for you. You will find here one of a series of articles designed to help you navigate the complexities of this process of employing and utilising new professional groups within your team.

Done well, it may actually be the best thing to happen to primary care in years. So, what is the ARRS and how might it help us?

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