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Latest Updates - 'Pearls' from the Red Whale

Our updates are ideal for bite-sized CPD and study group discussions!

"Great to see inclusions of bits for locums"

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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Red Whale Pearls are copyright free so you can print off as many hard copies as you like and forward soft copies to your colleagues to your heart's content. All we ask is that you acknowledge us as the source.

Calling all locums and would-be locums to our Locum Essentials Guide.

Find our specialised Pearls for Primary Care Nurses here.

HIV. To whom should we be offering tests? When should we offer repeat testing?

16 Aug 2017

The prevalence of HIV infection in England is 1.9/1000 people over the age of 15y. It is estimated that 17% of people living with HIV do not know their status. These rates are higher outside London, with nearly a quarter undiagnosed. HIV testing is critical to providing effective treatment, and preventing disease progression and mortality. Effective treatment also reduces viral load so preventing onward transmission.

Valproate and pregnancy just do not go together!

08 Aug 2017

Taking valproate during pregnancy is associated with a 30–40% risk of serious developmental disorders, and 10% risk of congenital malformations. It should not be used in girls or women of childbearing age (including teenagers), unless other treatments are ineffective or not tolerated.

In 2016, the MHRA strengthened its warnings about the risks of taking valproate medications ​​​​​​during pregnancy. This advise was updated and reissued in 2017 following a survey showing that 20% of women taking valproate were not aware of any of the risks of valproate in pregnancy. It has the following action points for primary care:

Could this be occupational asthma? Think about it in new onset asthma in an adult, or re-emergence of asthma in a patient who had ‘grown out of it’.

30 Jul 2017

About 1 in 10 people presenting like this will have occupational asthma. There are a number of high-risk occupations. Four times daily serial peak flows aid diagnosis, showing a dip on starting work and improvements when away from the workplace. Early referral to a chest physician/occupational physician is recommended. So, are you thinking to ask whether symptoms improve when away from work, or deteriorate when at work?

Click below to see our summary of occupational asthma.

Renal colic and alpha blockers: another twist in the tale!

25 Jul 2017

Previously, we highlighted a meta-analysis showing that alpha blockers aided stone expulsion, and sent you a Pearl all about it, as this seemed a great, easy treatment. Then a UK trial showed this was not the case, and we suggested you stopped using them. However, the latest meta-analysis suggests alpha-blockers do indeed aid stone expulsion, and reduce pain and hospital admission.
So, for patients with renal colic, we should again consider prescribing tamsulosin.
Click below to see our summary of this meta-analysis and management of renal colic.

Tamoxifen with fluoxetine, paroxetine or duloxetine – again!

18 Jul 2017

Yes, we know we are always banging on about this. We highlight the issue again because a multi-database cohort study published in the BMJ in 2016 showed no increased risk of breast cancer in people on tamoxifen and either paroxetine and fluoxetine. This sounds reassuring BUT the median follow-up was only 2.2 years! 

How should we assess and manage terminally ill patients with low mood?

13 Jul 2017

It is normal to feel sad and to undergo adjustment difficulties in the context of a terminal illness. However, clinical depression can also occur in this context. Relieving true clinical depression in terminal illness can help patients and their families to experience a good death.

Women who have had gestational diabetes need follow-up for the rest of their lives

05 Jul 2017

We have previously highlighted that NICE changed its diagnostic criteria for gestational diabetes. But how are we doing with follow-up? After delivery, women who have had gestational diabetes need a fasting plasma glucose at 6–13w (NICE specifically says NOT an OGGT!). If, somehow, this doesn’t happen, after 13w an HbA1c can be done (not sooner, because anaemia/blood loss at delivery may make it inaccurate). These women also need screening for diabetes ANNUALLY for the rest of their lives!

Aspirin and PPIs: more on this drug dilemma

28 Jun 2017

Two weeks ago, we sent out a Pearl on the harms of aspirin and mitigating these, particularly in those over 75, with PPIs. We have received a lot of questions about this, given the Pearl we sent in April focused on the risks of long-term PPIs. How do we balance these risks for any individual patient?
There are clear benefits with aspirin for secondary prevention of CVD, but also potential harms, some of which can be mitigated with PPIs. But, PPIs may affect the efficacy of aspirin, and have potential risks themselves.

Grapefruit juice does increase statin levels. But does it matter?

21 Jun 2017

For simvastatin, 1 glass of grapefruit juice can increase levels by up to 260%. Overall, some researchers have estimated this might actually have some cardiovascular benefits! It probably does not increase the risk of rhabdomyolysis, which is very rare.
Nevertheless, the MHRA still advises that grapefruit juice is avoided when taking simvastatin and atorvastatin.
Click below to see our summary of a trial reported in the DTB in 2016.

Aspirin harms: the latest research in context

14 Jun 2017

So low-dose aspirin is in the news again…this time it is all about the harms, particularly the harms as you get older.

It is also about how the increased risks can be mitigated through PPI use. Do you routinely give PPIs to those over 75y on aspirin? This study suggests you should.

So here is a summary of the latest research, set in the context of what we know already.

I hope you find this useful on a day of grim news from London.

Bone metastases

07 Jun 2017

Ted, at 89 years old, lives independently. Though still quite active, he admits he is starting to feel his age in a way he never has before. His prostate cancer, diagnosed 3 years ago, has not held him back. However, despite treatment, his PSA has started to rise. It is the relatively new, gnawing, aching, pain in his left hip that is making him feel old. Does Ted have a bony metastasis?

Breast, lung and prostate cancers account for 80% of all bony metastases. The main problems caused by bony metastases are pain, pathological fractures, spinal cord compression (an oncological emergency) and nerve root compression. Investigations involve bloods and a variety of radiological tests, though interpreting these may not be straight forward. ALP and calcium can be normal.

Drug interactions with contraception

30 May 2017

With wider uses of existing drugs (e.g. anti-epileptics for migraine and neuropathic pain) and new drugs on the market (e.g. HIV treatments), we need to be aware of any interactions with contraception. Enzyme-inducing drugs can impact on contraceptive efficacy. Numerous HIV medications, along with carbamazepine, phenytoin and other drugs, are strong enzyme-inducers.
Topiramate (now first line for migraine prevention) and St John’s wort (which patients may be purchasing over the counter) are included among the moderate/weak enzyme-inducers.

No additional precautions are necessary when prescribing antibiotics to women using combined hormonal contraception, except for enzyme-inducing antibiotics such as rifampicin/rifabutin.

Hypertension - diagnostic thresholds: are you using the correct ones?

23 May 2017

Hypertension - diagnostic thresholds: are you using the correct ones? A recent survey showed that more than half of GPs in 2015 were using the wrong thresholds to make the diagnosis!
In clinic, if the BP is ≥140/90, you should do ambulatory monitoring. If the ambulatory BP is ≥135/85, diagnose hypertension. Home monitoring is an alternative if ambulatory is not tolerated. For home readings, the diagnostic threshold is also ≥135/85: you do NOT adjust by 10/5. Clinic readings are not recommended for diagnosis.

Looking after yourself

17 May 2017

It seems that the pressure in primary care is mounting. With the cyberattack this week causing disrupted surgeries, and extra paperwork on top of the increasing pressures on the NHS, it can feel like the gods are conspiring against us. In times like these, it’s important to look after your biggest asset – that’s you, by the way!
On our Lead. Manage. Thrive! course, we frequently ask delegates to write down the first thing they stop doing when they are too busy or stressed. We then ask them how important that thing is for their mental health and wellbeing. Guess what? When we’re too busy and stressed, the first thing we drop from our lives is often the ONE THING THAT IS HUGELY IMPORTANT to keep us re-energised, well and mentally fit. This could be exercise, meeting up with a friend, connecting with a partner, doing yoga or meditation, reading a book, climbing a mountain………the list goes on.

Nausea and vomiting in palliative care. One chance to get it right.

10 May 2017

The gap left by the withdrawal of the Liverpool Care Pathway was filled in 2014 by a joint statement by interested parties called ‘One chance to get it right’. This stated that end of life care should be delivered around five pillars, one of which is individual care plans. Symptom control is an essential part of an individual care plan. Nausea and vomiting are often present in a palliative care context, and managing these symptoms effectively can make all the difference for a patient.

Quick-starting and bridging

02 May 2017

Teenage pregnancy rates have declined dramatically. There is debate about the reasons for this decline in what is being called ‘Generation Sensible’. Whatever the contribution contraception might be making to this decline (in particular LARCs), there is an important place for quick-starting and bridging for women, whether teenagers or older.

Evidence is emerging of risks with long-term use of PPIs, and the list is long!

26 Apr 2017

• Increased risk of:
- Clostridium difficile.
- Hospital acquired pneumonia.
• Association with:
- Increased risk of hip fractures in women.
- Dementia in older people.
- CKD.
- Low serum magnesium levels (leading to recommendations to check magnesium levels in those with symptoms and those also on other high-risk drugs, e.g. digoxin and diuretics). Symptoms of low magnesium are rare but often insidious (fatigue, dizziness), although they may be more serious (tetany, delirium, convulsions, ventricular arrhythmias).
• Possible associations with:
- Increased risk of MI.
- Community acquired pneumonia.

Neutropenic sepsis: NICE guidance

19 Apr 2017

A very serious complication that has the simplest guidance for GPs.
Neutropenic sepsis is a potentially fatal complication of chemotherapy treatment. The mortality rate has improved with rapid administration of antibiotics.

Managing stress

11 Apr 2017

Yes, we know the symptoms of stress, and stress management is something we discuss with our patients all the time. Yes, we know that stress and performance are related – for us, as well as our patients. But do we recognise it when it is happening within ourselves? Doctors are prone to stress and burnout, and we are not always good at recognising and acting on it.

Research published in 2016 by the King’s Fund showed that increasing workloads are the biggest source of stress for GPs. In our recent Red Whale survey of GPs, increasingly unmanageable workloads were described by 85% of the approximately 1,000 respondents as the single most negative aspect of their careers. The good news is that we CAN learn to manage stress. It CAN be different.

Miscarriage: frequently asked questions

04 Apr 2017

Miscarriage can be a devastating event. The hopes and dreams associated with a new pregnancy suddenly dashed. Women do not necessarily have contact with primary care at the time of miscarriage, and are often left with many unanswered questions. Some are unanswerable. These questions are likely to include: Why? Why me? What did I do wrong? What can I do to prevent a miscarriage if I try again? How soon should I try again? So, how can we best answer these questions, and what can we say about reduction of risk?

Is this bipolar?

28 Mar 2017

You have been treating Jim for depression but he seems now to be a little ‘high’. He has thrown in a good job and you recall that he has done this precipitously with previous employments. 

NSAID's: effectiveness and safety

22 Mar 2017

NSAIDs are often prescribed as part of the management of chronic pain, and this may be appropriate. However, NSAIDs have risks, and their benefits in chronic back pain and osteoarthritis are marginal. Diclofenac and high-dose ibuprofen are now contraindicated in patients with established IHD, peripheral arterial disease, cerebrovascular disease and congestive heart failure.

What, then, are the alternatives? When should we co-prescribe a PPI?

Click below to see our summary of a BMJ review looking at the effectiveness and safety of NSAIDs.

Should lesbian and bisexual women have a smear?

16 Mar 2017

And, while we are looking at medical topics making the news, another Pearl that we sent out in 2015 warrants a reminder. The BBC, as well as the Telegraph and the Sun, have picked up on the LGBT Partnership focus for National LB Women’s Health Week. This highlights the low levels of uptake for cervical smear tests among lesbian and bisexual women, and the issue of misinformation about the need for cervical smears.
Should lesbian and bisexual women have a smear?

Sepsis - a reminder

15 Mar 2017

“The family GP said he just needed Calpol, but Patrick's mother was still concerned and took him to hospital.” This is from a BBC article “The biggest killer you may not know” written to raise awareness of sepsis. 
The article and the comments that follow it on the BBC website show how challenging it can be to make the diagnosis of sepsis, and how devastating it can be if it is missed or the diagnosis is delayed. One of the comments poignantly says “I hope the GP was made aware of his huge mistake so he/she could learn from it”.
We sent out a Pearl on the new NICE sepsis guidelines in July 2016 when they were released. However, with this publicity raising patient awareness, a reminder about the sepsis guidelines is timely.

Introducing our new 'Locum Essentials Guide'

08 Mar 2017

Are you a locum? Are you about to become a locum? Perhaps you are thinking about this as a career option, either short or long term? We know many of you are locums or are entertaining the idea of becoming locums, perhaps after a salaried career or a baby, or even after training.
This can be a scary move. You have to think about the financial aspects: invoicing, pension, tax, expenses. Then there are the challenges of clinical management, and the difficulties in meeting all the requirements for revalidation when you are not practice based. We may have just what you need!

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