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Latest Updates - 'Pearls' from the Red Whale

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Supporting you throughout your CPD journey - one update at a time

Our regular updates or ‘Pearls’ are topical items relating to primary care. Each one is drawn from the latest research, clinically relevant to issues in general practice, and linked to an article in our handbook.

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Acute upper gastrointestinal bleeding

04 Dec 2019

"I never look at my poo, I just flush it away", says Tony in response to your question trying to ascertain whether he has melaena. Tony is a 46-year-old who admits drinking more than he should and presents with epigastric pain. He took some ibuprofen last week for a painful shoulder. So, has Tony had an acute GI bleed?

Acute upper GI bleeding is common and serious, with 10% mortality. Peptic ulcer is the most common cause, followed by gastritis/duodenitis.

In the acute phase, a normal haemoglobin and normal blood pressure do not rule out a substantial bleed so we should not be reassured if these are normal. A raised pulse rate is more sensitive.

The bottom line is, we should refer all patients with a good history.

So, what are you going to do with Tony?

And what about management after an acute upper GI bleed? Can your patient ever again use NSAIDS? And what if they were on antiplatelets or anticoagulation?

Click below to see our summary of a 2018 BMJ review regarding acute upper GI bleeds. We hope this summary will help you think through any such clinical dilemmas.

Chronic pain

25 Nov 2019

A cry we are hearing a lot on our GP Update and MSK courses at the moment is, "We can't use opiates, we can't use gabapentinoids, what can we use for patients with chronic pain?".

Unfortunately, there is not a quick-fix, easy answer: no single tablet that will cure chronic pain. But there is a lot we can do. Our understanding of the neurobiology of chronic pain has changed beyond recognition since many of us were at medical school. In our next VA webinar, we will unpack this and start to talk about consultation strategies, specific self-mangement skills and great resources.

The International Association for the Study of Pain (ASP) defines pain as: an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

“Jaw dropping” research on hypertension!

19 Nov 2019

"Jaw-dropping" is how Dr Mark Porter, writing in The Times, described recently-published research looking at when is the best time of the day to take blood pressure medication.

And the conclusion of the study: bedtime!

The bedtime dosing group had almost half as many cardiovascular events as the morning dosing group.

Many of your hypertensive patients may be aware of this research from the media attention it has been given. They may be wondering what it means for them.

We have summarised the findings of the study published in the European Heart Journal looking at why this might be, and what it means in practice.

Click below to see our summary of the 2019 European Heart Journal article.

Varicoceles and male infertility

13 Nov 2019

You have reassured Charlie that the swelling he felt in his scrotum is just a varicocele and is not cancer. However, he still looks anxious and asks, "will this mean I cannot have a child?".

Varicoceles are common, occurring in 15% of adolescent boys and men. Two-thirds of men with a varicocele do not have problems with fertility, though varicoceles do increase scrotal temperature, reduce testicular perfusion, and are associated with reduced sperm quality in observational studies.

Embolisation of large varicoceles may improve sperm quality. However, NICE concludes that varicocele surgery should not be offered as fertility treatment because it does not improve pregnancy rates.

Acute severe asthma

05 Nov 2019

We should treat every attendance with an asthma exacerbation as severe asthma until proven otherwise.

So, what suggests that an acute asthma exacerbation is severe or life threatening?

PEFR is an important indicator, and we need to be able to measure oxygen saturation, but we should not rely on a single sign. We must look at the whole picture.

And then, for management:

How should we give sabutamol? Should we give oxygen? Should we give prednisolone? Should we give antibiotics?

And then, for management:

How should we give salbutamol? Should we give oxygen? Should we give prednisolone? Should we give antibiotics? When should we admit?

Click below to see our acute asthma protocol for adults and for children based on SIGN/BTS guidelines. You might wish to print these two A4 pages for your emergency bag or treatment room wall, or use them as the basis of your own practice protocol.

Lung cancer

31 Oct 2019

Lung Cancer: the UK continues to lag significantly behind other European nations in 5- and 10-year survival rates from lung cancer.

We can make earlier diagnosis in primary care by:

  • Improving patients awareness of symptoms - 'Be Clear on Cancer' has done this.
  • Having a low threshold for referring for CXR in at-risk patients - CXRs are cheap, widely available and relatively harm-free!
  • Not being falsely reassured by negative CXR in patients with persistent symptoms.

Remember, beware the negative CXR - if we still have a degree of suspicion, we should refer!

So, when should we order a chest radiograph?

Lung cancer does not always present with a clear symptom signature, and affected individuals often have comorbidities that could confuse the picture. While haemoptysis is the most predictive isolated symptom, it only occurs in 20% of those with a final diagnosis of lung cancer. Remember more unusual presentations such as thrombocytosis, appetite loss, shoulder pain and worsening spirometry, especially in smokers. NICE offers clear guidance on how we should approach patients presenting with symptoms that could be suggestive of lung cancer.

Subclinical hypothyroidism. Overdiagnosis or worth treating?

23 Oct 2019

We have several dilemmas when we encounter a raised TSH with normal T4. Each year, a small percentage of these patients will develop overt hypothyroidism. But with a single raised TSH of less than 7mIU/L, there is a 50% chance of the level normalising over 2 years.

What about CHD risk? A meta-analysis has shown that, overall, there was no difference in CHD incidence, CHD mortality or overall mortality between those with subclinical hypothyroidism and those who were euthyroid. However, those who had a TSH ≥10mU/L at presentation had a significantly increased risk of CHD and CHD mortality, but no difference in overall mortality.

There is evidence that treating subclinical hypothyroidism does not improve symptoms or quality of life.

There is insufficient data to look at whether treatment reduces the risk of CVD.

Hormonal contraception and depression

14 Oct 2019

"Can I change to a different pill?", Abigail asks. "I have been having terrible mood swings. It all seems to be since I started the pill 3 months ago. This is just not like me. My partner and friends have noticed it and are worried. It must be the pill."

So, what is the evidence around hormonal contraception and depression? And how will you advise Abigail?

  • Research from Scandanavia has found that use of hormonal contraception may be associated with increased antidepressant use and an increased risk of suicide.
  • The FRSH points out that there are limitations to studies in this area, and they do not prove a casual link between hormonal contraceptive use and depression.
  • Mood disorders in women may be mutifactorial.
  • A history of depression is NOT a contraindication (UKMEC 1) to any method of contraception.

Several indications for use. Different cut-off thresholds for different uses. What is all the fuss about FIT?

09 Oct 2019

The faecal immunochemical test (FIT) is a new way to test for occult blood in stool. It is replacing the traditional guaiac-based faecal occult stool test.

FIT can detect human haemoglobin in stool at very low levels. It has a much lower false positive rate than guaiac testing because it is not influenced by food consumed. It is specific for lower GI blood loss and requires one test, rather than three – so, if your patient is sent just one test kit, the FIT is being used. It is a quantitative test so the amount of blood in the stool can also be determined. This allows different thresholds to be set which will adjust the sensitivity and specificity of the test.

There are three ways the FIT test can be used, each of which involves different cut-off thresholds being applied.

Emollients are dangerous!

02 Oct 2019

People can, and do, die from fire associated with emollient use.

In 2018, the MHRA recommended that patients should be given 'clear advice not to smoke or go near naked flames, and information about the risk of severe burn injury or death when clothing, bedding and dressings with emollients dried on them are accidentally ignited'.

This advice applies to all emollients, whether they contain paraffin or not.

Emollients are the mainstay of treatment for everyone with eczema. They should continue to be used when stepping up treatment.


26 Sep 2019

Osteoarthritis is extremely common and a growing problem in the UK. We spend between 1 and 2.5% of our GDP on the direct costs of this condition, e.g. drugs, physiotherapy and surgery; the indirect costs, e.g. early retirement and disability, are likely to be even higher.

And yet, many patients with osteoarthritis report feeling unsupported and feel they have to ‘accept’ their arthritis as an inevitable part of ageing.

Primary care can make a big difference to patients with osteoarthritis, but what can we say, and how we say it, really matters. The old adage of 'wear and tear' just doesn't fit the bill. If we think about it, phrases like this imply an inevitable need for surgery and don't make it particularly likely that our patients will engage in exercise and movement...I mean, if your brakes are 'worn and torn', you don't want to take the car out for a long drive.

Addiction to prescribed drugs, summary of PHE data and some tips to help!

19 Sep 2019

'1 in 4 people take addictive medicines', finds a Public Health England review. The Mail Online says, 'The NHS must take action!'

So, where have these numbers come from - and what can we do?

These reports were based on PHE prescribing analysis using CPRD data from 2017. The analysis looked at 5 drug classes: antidepressants, benzodiazepines, Z-drugs, opiods and gabapentinoids.

In 12 months between 2017 and 2018, 11.5 million adults in the UK were prescribed at least one of these drugs. To put this into context, this means around 17% of the adult population were being prescribed antidepressants and around 3% were being prescribed gabapentinoids. These prescription rates are higher in women, and higher in areas of deprivation.

The average duration of prescription has gone up from 3 months to over 12 months since the last evaluation in 2015. This report also attracted a fair bit of controversy about whether antidepressants should have been lumped indiscriminately in with these other drug classes, and this is a legitimate point.


12 Sep 2019

Negotiating a deal. Pre-conditions. Blocking a deal. Leaving with no deal. This has been the seemingly endless coverage of the big picture of Brexit. But negotiation and deal making is also part of life in the smaller picture of primary care.

Do we do any better? Are we any better equipped? What skills do we have in negotiation in the everyday world of primary care?

Many of us find the concept of negotiation a little challenging and anxiety-inducing.

We might rarely have to negotiate finances, job conditions or contracts, but that's not to say we don't ever negotiate. We are entering the new world of Primary Care Networks - this is likely to involve negotiation. And what about the times we have to persuade someone to do a scan or admit a patient? Or when we identify something we would like to change in our own practices? Or when swapping a late evening or weekend surgery?

Diabetes in remission: a story of hope?

02 Sep 2019

"We can control your diabetes using drugs for the rest of your life. Or, if you can change your lifestyle and lose weight, there is a good chance your diabetes will go away. Which would you prefer?".

There is increasing evidence for the benefit of low-carb diets in diabetes. But these involve significant lifestyle changes and hard work on the part of our patients in order to achieve the benefits.

The conversations we are having with our diabetic patients are changing. So, the big question for us is, how do we enable our patients to make the changes required?

Click below to see our summary of trials looking at low-carb diets in diabetes published in the Lancet and the BMJ in 2018.

If you are interested in learning more about this and want to take the next steps in building your skills at empowering your patients to embrace lifestyle change, click to join us for our next Deep Dives webinar "Diabetes in remission: A story of hope" on 10th September 2019 at 20.00.

You will get chance to quiz Dr David Unwin on how we can make this stuff work in real life general practice. We might just feel a bit inspired!

Self-help books for mental health issues

29 Aug 2019

"I don't like talking with strangers", or "That's not for me". I imagine you have received similar responses when suggesting referral to IAPT services for support with mental health issues.

If patients can engage with a book, there are some great resources that might be all they need, or might even break the ice on the idea of seeking approptiate talking therapy.

The Reading Agency with the Society of Chief Librarians has complied a list of books recommended for adults, and a list for young people. We hope that both you and your patients will find these resources helpful.

Click below to see the lists of self-help books for adults and for young people.


21 Aug 2019

"Boris Johnson orders action to stop measles spread", was the BBC headline this week. This was followed by an article entitles "Why is the UK seeing a rise in measles cases?".

In the first quarter of 2019 there were 231 confirmed cases in the UK. The UK has lost its measles-free status, 3 years after the virus was 'eliminated' in the country. This follows on from 2018 when there was a marked increase in reported measles cases, with 991 confirmed cases in England and Wales compared with 284 cases in 2017. Grim reading!

“My HRT is out of stock – what can I have instead?”

14 Aug 2019

By the time you get to deal with the drug query list at the end of the day, you may not be on top form, and finding appropriate alternatives can send your brain into meltdown. I think there is a real risk of us giving someone the wrong thing - and if that is unopposed oestrogen to a woman with a uterus, that really matters!

Our Women's Health team has put together this amazing resource: a GEMS on HRT covering the key things you need to know. And on the back page is a wonderful table listing the main types of HRT and equivalents. Print a copy for every room in your surgery now!

We hope this will help you as you plough through the drug query list!

If you want to know more, click to watch our Deep Dives webinar on the menopause and HRT.

Cellulitis: how do you know it is cellulitis?

30 Jul 2019

Try the leg raise test to avoid overdiagnosis of cellulitis and unnecessary antibiotic treatment.

With the patient lying horizontal, elevate the affected leg to 45 degrees for 1-2 minutes.

The erythema of cellulitis persists, whereas erythema secondary to vascular causes will commonly fade.

A test to try next time you are assessing for possible cellulitis and considering prescibing antibiotics.

And if you do prescribe antibiotics.............

You think your patient has erythema migrans. Now what?

24 Jul 2019

Lyme disease-carrying ticks can be found all over the UK. And with this lovely warm weather, many of our patients (and hopefully us!) are taking to woodland areas for nice shady walks. Inevitably, we will see a whole host of bites, most of which will resolve without any medical intervention.

However, what if we see a rash suggestive of erythema migrans? This is usually a red, non-itchy, painless rash which may develop central clearing. It can appear any time from 3 days to 3 months after a tick bite, but most commonly occurs between 1-4 weeks.

Hydroxychloroquine and retinopathy risk – do you need to take action?

18 Jul 2019

Retinopathy due to long-term hydroxychloroquine may initially be asymptomatic but is sight threatening - and it is more common than previously thought!

The 2018 Royal College of Ophthalmology recommendations on screening advise baseine examination, then screening after 5 years on treatment (including fundal photography - so eye clinic referral). Those with additional risk factors (e.g. tamoxifen use or renal impairment) may need earlier screening.

Walking aids and osteoarthritis

17 Jul 2019

You've not noticed before, but as you observe elderly Mrs Kelly walk into your consulting room, you see that she seems to waft her walking stick in the air. It appears to give little support. You realise you have no idea how long she has had the stick. No idea where she got it from. And no idea whether or not it's the correct size for her!

Individuals with osteoarthrosis using a walking stick have less pain and better quality of life, so Mrs Kelly had the right idea when she accepted a walking stick her sister no longer needed.

To dip or not to dip: that is the question!

11 Jul 2019

The diagnosis of UTI in women is primarily clinical. If symptoms are highly suggestive of cystitis, we can treat without doing any further tests. Only arrange urine testing if there is diagnostic uncertainty, to guide antibiotic choice, or if there are signs of upper urinary tract infection. Always send an MSU before starting treatment in a patient with upper UTI symptoms. The aim of urine culture is to identify bacteria and sensitivity to antibiotics.

Dipsticks are not as sensitive as clinical symptoms at picking up UTIs. Only perform a dipstick to exclude or help confirm a diagnosis of UTI in a woman with minimal symptoms (e.g. if there are mild or ≤2  symptoms present).

Rashes and exposure to rashes in pregnancy

03 Jul 2019

There are two scenarios to consider here: a pregnant woman presenting with a rash; and a pregnant woman exposed to a rash, but currently asymptomatic.

There are four viral illnesses that can cause problems for the non-immune pregnant woman. Varicella and parvovirus (common in children in the UK), and rubella and measles (less common in the UK but should be considered).

Remember that pregnant women can also develop meningococcal septicaemia and other general and dermatological conditions in pregnancy. 

Obstructive sleep apnoea and snoring in children

26 Jun 2019

Snoring is relatively common in children and is usually a 'normal variant'. But, in a small number of cases, snoring may be caused by obstructive sleep apnoea.

The good news is that adenotonsillectomy will cure simple obstructive sleep apnoea in the vast majority of children.

Exploring night-time symptoms and asking about day-time impact (behavioural problems, irritability, etc.) along with ENT examination will help us determine which children have obstructive sleep apnoea.

Menopause: Non-HRT treatments

21 Jun 2019

HRT is by far the most effective treatment for menopausal symptoms and, where possible, should be our first choice. But it is contraindicated in some women and others do not tolerate it or prefer not to use it. These women may still seek help for their symptoms. So, what can we offer them?

There are pharmacological and non-pharmacological alternatives for which there is an imperfect but evolving evidence base, summarised by the BMJ (BMJ 2017;359:j5101). There are also some new drugs on the horizon.

Click below to read more about alternative treatments for menopause symptoms.

For much more information about the menopause and an opportunity to have all your questions about HRT answered, click to join our Women's Health team for our next Deep Dives webinar, The Menopause Laid Bare, streaming LIVE 25 June @8pm.