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Eating disorders – a longer read…

22 Feb 2024

Next week is Eating Disorders Awareness Week, and we are sharing our whole article to offer us all the chance of a refresher. Early intervention makes a big difference, especially for anorexia nervosa. Primary care has an important role to play, but we need the support of specialist pathways – and, we know, waiting lists can be LONG! 

More info PDF

Eating disorders – a longer read…

Next week is Eating Disorders Awareness Week, and we are sharing our whole article to offer us all the chance of a refresher. Early intervention makes a big difference, especially for anorexia nervosa. Primary care has an important role to play, but we need the support of specialist pathways – and, we know, waiting lists can be LONG! 

So… 

  • Did you know there are five eating disorder subtypes? 

  • Have you heard of ARFID? 

  • Did you know that referral shouldn’t be based on BMI alone? 

  • Do you know the SCOFF screening tool – and how it fits into a global assessment? 

For answers to these questions and lots more useful information, click on our PDF!

Can you measure my oestrogen levels? I think I need to increase my HRT

15 Feb 2024

Increased menopause awareness means we may meet challenges in primary care that are not covered by NICE or other guidelines. This may present dilemmas and uncertainty. We may encounter patients who have been prescribed above-licence doses of HRT, or who are requesting increased doses due to persistent menopausal symptoms.  

More info PDF

Can you measure my oestrogen levels? I think I need to increase my HRT

Increased menopause awareness means we may meet challenges in primary care that are not covered by NICE or other guidelines. This may present dilemmas and uncertainty. We may encounter patients who have been prescribed above-licence doses of HRT, or who are requesting increased doses due to persistent menopausal symptoms.  

 We may be asked to check, or wonder ourselves, whether an oestradiol level would be helpful to ensure that the patient is absorbing HRT, and that levels remain within ‘normal range’. 

In this week’s Pearl, we review the available evidence and guidelines for measuring oestradiol in this context. 

Headlines: 

  • Evidence is sparse and does not suggest a clear association between oestradiol levels and menopausal symptoms or HRT dose.  

  • BMI, type of assay and fluctuating endogenous production of oestrogen can all affect the results.  

  • The British Menopause Society states that routine testing is unnecessary and expensive.  

Click on the PDF button to read more!

Want to learn more about menopause? Join Helen and Lucy on the Red Whale sofa on 21 February 2024 for the Menopause course, where we take a holistic approach and share uncertainties about current evidence - or watch any time on demand.  

Erox-what and supporting men with concerns…

08 Feb 2024

Erectile dysfunction has been in the media, and we may be getting asked about it: Eroxon is a new topical treatment for erectile dysfunction. It is being widely advertised in the UK and is available over the counter. 

More info PDF

Erox-what and supporting men with concerns…

Erectile dysfunction has been in the media, and we may be getting asked about it: Eroxon is a new topical treatment for erectile dysfunction. It is being widely advertised in the UK and is available over the counter. 

A BBC TV programme on erectile dysfunction aired over Christmas. ‘Men Up’ (currently available on BBC iPlayer) follows 5 men from Swansea who were part of the first trial for Viagra. But it is actually a story about much more, and may have helped men feel more comfortable talking about this issue. 

So, are we ready for these ‘door handle consultations’?  

  • Are we proactively asking higher-risk men about this? 

  • Are we contextualising this as part of a cardiometabolic disease? 

  • Are we measuring a morning total testosterone? 

Read all in this week’s Pearl!

Contraception: there’s a new kid in town…

01 Feb 2024

We know that, when it comes to contraception, LARCs should be our first choice because they are more effective – but they don’t suit all women and some prefer alternatives. 

More info PDF

Contraception: there’s a new kid in town…

We know that, when it comes to contraception, LARCs should be our first choice because they are more effective – but they don’t suit all women and some prefer alternatives. 

The POP is now considered a mainstream alternative to combined hormonal contraception, and there have been a few changes over recent years: 

  • Desogestrel-based pills are now available over the counter and online. 

  • A new drospirenone-based pill, Slynd, became available in the UK in January 2024.  

  • It may offer some women a more favourable bleeding pattern. 

  • It has a 24h window, offering more flexibility. 

  • It is more expensive than existing POP preparations. 

  • It has different and more complex missed pill rules.  

  • There are some additional precautions to the usual UKMEC because drospirenone is an aldosterone antagonist and there is a potential risk of hyperkalemia. 

For more information on this and all things POP, read our PDF!

Want a contraception refresher? Taking on contraception as a new part of your role? Why not join Lucy on the Red Whale sofa on 2 February for our live-hosted Contraception and Sexual Health Together event? Or watch any time on demand. 

Measles: an update

25 Jan 2024

In 2016, the WHO declared the UK to be free of measles. Sadly, this is no longer the case, in large part down to incomplete vaccination coverage. Vaccination rates are at the lowest in a decade, and, in January 2024, the UKHSA declared a national health incident due to a significant measles outbreak in the West Midlands. 

More info PDF

Measles: an update

In 2016, the WHO declared the UK to be free of measles. Sadly, this is no longer the case, in large part down to incomplete vaccination coverage. Vaccination rates are at the lowest in a decade, and, in January 2024, the UKHSA declared a national health incident due to a significant measles outbreak in the West Midlands. 

The UK is not alone – the WHO reports that there is a year-on-year increase in measles cases worldwide (UNICEF - measles cases are spiking globally). 

In this week’s Pearl, we summarise the BRAND NEW UKHSA National Measles Guideline released this month.  

Here are the headlines:

  • Measles is EXTREMELY infectious. In the UK, a single index case is likely to result in 15–20 cases (that’s an R number of 15–20; think of that in the context of COVID R numbers!) (UKHSA).
  • Most infections are transmitted via the respiratory route. 
  • In the UK, there were 54 confirmed cases in 2022.
  • Between October 2023 and 18 January 2024, there were 216 confirmed cases and 103 probable cases in the West Midlands, the majority in children under 10y (UKHSA data, accessed January 2024). 
  • Outbreaks and transmission tend to occur in unvaccinated or incompletely-vaccinated individuals. 
  • Because measles is so transmissible, MMR coverage needs to be in the order of 95% (WHO target).
  • Current MMR coverage in the UK is the lowest it has been in a decade (UKHSA data, accessed January 2024):
  • In England, around 85% of 5-year-olds are covered by 2 MMR vaccines at age 5y.  
  • 10% of children are completely unprotected, rising to 20% in London. 
  • Incubation period is from 7 to 21d (typically 10 to 12d). 
  • Infectious period is 4d before to 4d after onset of rash. 
  • Think about measles in unvaccinated or incompletely-vaccinated individuals with a flu-like illness with conjunctivitis, followed by a rash.
  • Offer opportunistic vaccination to all aged >1y with an incomplete vaccination history.

For more information on how to spot it and what you do if you suspect it, click on the PDF button to read more

His head is all squished on one side…

18 Jan 2024

Now, this could mean many things, but hopefully if this is a call to general practice, this will be a worry about a baby’s non-acute asymmetrical head.  In most cases, this will be “normal” and relate to the babies preferred positioning (positional plagiocephaly) but rarely it could point to a more serious underlying problem.  

More info PDF

His head is all squished on one side…

Now, this could mean many things, but hopefully if this is a call to general practice, this will be a worry about a baby’s non-acute asymmetrical head.  In most cases, this will be “normal” and relate to the babies preferred positioning (positional plagiocephaly) but rarely it could point to a more serious underlying problem.  

In this week’s Pearl we explore:  

  • How should we assess an infant with an asymmetrical head? 

  • What are the different types of craniosynostosis? 

  • Who needs referral? 

  • What advice can we give for positional plagiocephaly? 

Scabies surge: spotting it and managing it (if you can get hold of the treatments!)

11 Jan 2024

“Doctors report ‘nightmare’ surge in scabies across UK” (Guardian, 1 January)  If you’re already feeling a little itchy, you’re not alone. This week’s Pearl focuses on scabies.

More info PDF

Scabies surge: spotting it and managing it (if you can get hold of the treatments!)

“Doctors report ‘nightmare’ surge in scabies across UK” (Guardian, 1 January)  If you’re already feeling a little itchy, you’re not alone. This week’s Pearl focuses on scabies.

Scabies can be difficult to spot and tricky to manage, both because the treatment has to be applied in a very specific way AND because there are shortages of both first-line treatment options!

Take home messages are:

  • It’s usually a clinical diagnosis based on history of itch and/or typical rash – you don’t HAVE to see a mite or do skin scrapings.
  • Look in webs of fingers/toes, sides of hands and feet, the belt line, nipples and buttocks.
  • Permethrin 5% cream is the first-line treatment (malathion 0.5% is an alternative).
  • Make sure the person knows how to use the permethrin (click the full Pearl for details).
  • Treat the whole body, the whole household and close contacts all at the same time. Repeat 7d later.
  • Outbreaks in closed settings need special consideration. The UKHSA can support.

To learn more, or if you are faced with an outbreak in a local residential home or hall of residence, click to read this week's Pearl!

Actively beat the new year blues…

04 Jan 2024

We all know that new year is a notoriously TERRIBLE time to make sweeping resolutions or try to embark on drastic lifestyle change. But, for many of our patients (and, let’s face it, many of us), becoming more active is achievable. And, unlike almost all other things in medicine, it’s all upside!

More info PDF

Actively beat the new year blues…

We all know that new year is a notoriously TERRIBLE time to make sweeping resolutions or try to embark on drastic lifestyle change. But, for many of our patients (and, let’s face it, many of us), becoming more active is achievable. And, unlike almost all other things in medicine, it’s all upside!

For this week’s Pearl, we would like to share our article on how we can build conversations around physical activity into our consultations.

Discover: 

  • Are brief interventions effective at increasing activity levels?
  • Can I make a difference in one minute?
  • Is physical activity ‘safe’ for people with long-term conditions? 

 

Spoiler alert: the answer to ALL these questions is YES!

 

  • Do I have to run/cycle/put on lycra?
  • Are we role-modelling the behaviour we would like to see?
  • Will it cost a fortune to make our practice more active?

Spoiler alert: the answer to ALL these questions is NO!

Click here to read more – and, if you would like to reinvigorate yourself and your practice, watch out for the Red Whale Lifestyle Medicine course launching later this year. 

The heating’s back on – beware carbon monoxide poisoning!

14 Dec 2023

Carbon monoxide poisoning is rare but easily missed. Making the diagnosis relies on spotting patterns in the history. 

More info PDF

The heating’s back on – beware carbon monoxide poisoning!

Carbon monoxide poisoning is rare but easily missed. Making the diagnosis relies on spotting patterns in the history. 

Here are some headlines:  

  • The person may describe a range of non-specific “virally symptoms” (see the table in the whole article) that are worse in certain places and resolve when away from them! 

  • Don’t EVER use a pulse oximeter to check for carbon monoxide poisoning – the reading can be falsely high.  

  • Refer to A&E by ambulance and give high flow oxygen through a non-rebreathe mask while waiting.  

  • Think: who else was in that environment and might be affected? 

Sore throat and tonsilitis: All you ever wanted to know!

07 Dec 2023

Do you remember about a year ago, we were in the grip of media reporting on the scarlet fever and invasive group A strep “epidemic” – we witnessed a huge surge in demand across primary care setting and antibiotic prescribing soared. And yet we know that most cases of sore throat do not need antibiotics. 

More info PDF

Sore throat and tonsilitis: All you ever wanted to know!

Do you remember about a year ago, we were in the grip of media reporting on the scarlet fever and invasive group A strep “epidemic” – we witnessed a huge surge in demand across primary care setting and antibiotic prescribing soared. And yet we know that most cases of sore throat do not need antibiotics. 

In this week’s Pearl, we offer you a whirlwind tour of all things sore throat. Whatever your role – there’s something for everyone: 

  • How do we assess sore throats?  

  • Which scoring system should we use?  

  • How useful are throat swabs? 

  • Who needs antibiotics and which should we choose? 

  • Do corticosteroids have a role to play? 

  • When should we refer for tonsillectomy? 

For answers to all these questions – read this week's Pearl!

Galleri: a blood test that will revolutionise cancer diagnosis?

30 Nov 2023

“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. 

More info PDF

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

23 Nov 2023

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. 

More info PDF

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?

16 Nov 2023

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. 

More info PDF

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.  

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