Follow us Facebook Twitter LinkedIn

03330 093 090
Monday to Friday 9.00am to 5.00pm
Charged at the national landline rate

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.

Like these updates? Sign up now

If you'd like these Pearls sent directly to your inbox, just join our mailing list by completing the form below. We promise never to pass your details to anyone else - and especially not to pharmaceutical companies - we are run by GPs, don't forget!

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.

Find our specialised Pearls for Primary Care Nurses here.

Travelling with medication – what advice (if any!) should we be giving our patients?

06 Dec 2017

“The everyday medicines that could land you in prison if you take them on holiday” (The Mirror, 14 November 2017)

Laura Plummer, a British tourist, is currently in an Egyptian prison following her arrest for carrying tramadol into Egypt without a permit. This case has recently caused controversy in the mainstream media. 

Many practices offer travel clinics, often as a private service run by practice nurses. So, what advice, if any, should we be giving to our patients about this issue?
 

“The majority of GPs in England (80%) are unfamiliar with the national physical activity guidelines”, concluded a BJGP article in October 2017

30 Nov 2017

The article claims that “physical activity brief advice in health care is effective at getting individuals active”, and goes on to say that “it has been suggested that one in four people would be more active if advised by a GP or nurse” (BJGP 2017 doi.org/10.3399/bjgp17X692513). NICE guidance in 2013 repeated the Chief Medical Officer’s 2011 recommendations for physical activity.

“UK ‘eliminates measles’ for the first time” was the BBC headline recently, quoting a World Health Organization report

21 Nov 2017

Sounds great, BUT there were 477 confirmed cases of measles in the first 9m of 2016 in the UK! So how does that add up? And does this mean we can be more complacent about immunising children?

WHO classes a country as having eliminated the disease when it has stopped it freely circulating for at least three years. This is not the same as eradication! Clusters of infection are still occurring in the UK, but herd immunity has ensured that wider transmission has not followed. Population immunity of more than 95% is necessary to prevent ongoing transmission. It is brilliant to have achieved elimination of measles, and this is testament to the dedication and hard work of our primary care teams.

Chronic pelvic pain in women of reproductive age is common

15 Nov 2017

Like all chronic pain syndromes, pelvic pain carries with it significant personal, social and economic burdens. Chronic pelvic pain is defined as intermittent or constant pain in the lower abdomen or pelvis for a minimum of 6m, and not occurring exclusively during menstruation, intercourse or as a result of pregnancy. 
The processes responsible for chronic pelvic pain are poorly understood, but are believed to be due to a combination of factors with physical, psychological and social elements. It often overlaps with IBS and interstitial cystitis.

Analgesic patches in palliative care

08 Nov 2017

The following covers the essentials of analgesic patch use in palliative care. It is not aimed at experts in palliative care! So, if like us you are not an expert, you might find it useful to read on.

Analgesic patches are useful in situations of poor swallowing, or poor enteric absorption. They should not be used in unstable pain, or where skin absorption may be impaired. When converting to transdermal opiates, we should choose a dose at the lower end of the conversion range. They should be used with extreme caution in opiate-naïve patients. 

Intra-operative floppy iris syndrome (IFIS) – yes, it is a real condition and we do need to know about it!

01 Nov 2017

While this is an issue eye surgeons deal with, we in primary care must also be aware of it because it is significantly more common in men who are taking tamsulosin (so, quite a lot of our male patients).  A large case–control cohort study published in the JAMA showed that adverse events following cataract surgery were significantly more common in men who were taking tamsulosin, or had recently stopped taking it. Those who had stopped taking tamsulosin more than 12m before surgery were not at increased risk.

Managing upwards. Yes, you read it correctly!

24 Oct 2017

If the organisation you work for has a top down structure (and most organisations do), managing upwards can be an essential skill.

Managing upwards means consciously working with your boss to obtain the best results for everyone. It involves building understanding, cooperation and trust, while acknowledging that both parties often have a different perspective. It is about developing a trusting relationship with your boss so that you, your boss, the organisation and, ultimately, patients reap the benefit. 

Biliary atresia: a rare, but serious, liver disease that presents with neonatal jaundice

16 Oct 2017

The diagnosis may be missed or made later than is ideal because of confusion with physiological or breast milk jaundice. In the first weeks of life, most infants appear well and there is rarely a family history of liver disease. If we do not think of this diagnosis in infants with prolonged jaundice or pale stools and dark urine, we will miss it.

Women aged 35–44y with systemic lupus erythematosus (SLE) are fifty times more likely to suffer an MI compared with age-matched controls

11 Oct 2017

SLE is a rare and complex condition. 

•    In the first 5 years after diagnosis, disease activity and infections are the commonest cause of morbidity and mortality. 
•    Thrombosis is the commonest cause of death over the next 5 years. 
•    The overall mortality rate in the first 10 years is 8%!
•    In one study, over one-quarter of patients with SLE were found to be depressed. Dissatisfaction with support, a poor understanding of the disease, and unsatisfactory contacts with medical staff were all cited as contributing to this. 

Is CRP point-of-care testing helpful in deciding which patients with LRTI need antibiotics?

04 Oct 2017

NICE recommends:
•    Offer point-of-care CRP tests ONLY in non-pneumonia LRTI where there is uncertainty about prescribing antibiotics. 
•    CRP tests should NOT be used in pneumonia – all these patients should be prescribed antibiotics.

However, some words of caution. Although trials of reliability have shown point-of-care tests to be as good as laboratory CRP tests, and some trials have shown reduced use of antibiotics with point-of-care testing, not all trials are positive, and many clinical trials have been funded by the manufacturers.

The second edition of our Locums Essentials Guide

26 Sep 2017

Our Locum Essentials Guide was so well received that we have published a second edition, which includes new material on Administrative Essentials, as well as important Surgery Essentials.

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, especially managing medical emergencies in a context that might be unfamiliar to you. Our guide may be just what you need! 
 

“How people die remains in the memory of those who live on.” Cicely Saunders

20 Sep 2017

Agitation, restlessness and delirium are distressing to those around them. Research shows this distress can be reduced if you can educate families about it BEFORE it occurs. It is important to remember that ‘normal’ features of dying may be interpreted as agitation/distress by family and carers, for example Cheyne–Stokes breathing and tracheal secretions. 

When it comes to delirium, the key is recognising it. Then, think about the cause. In terminal care, liver failure, renal failure, hypoxia, infection and hypercalcaemia are among the commonest causes.

How often do you diagnose 'genitourinary syndrome of menopause’? Erm…what, I hear you say?

12 Sep 2017

This is the new name for vulvovaginal atrophy, a common and easily treatable condition. Yet only 10% of women who would benefit from treatment actually receive it! 

A Cochrane review suggests that one of the reasons it is underdiagnosed is that we don’t ask specifically about urogenital symptoms.

•    Genitourinary syndrome of menopause (GSM) can affect up to 50% of women.
•    It tends to become apparent 4–5y after the menopause.  
•    Unlike vasomotor symptoms, it does not resolve spontaneously and may become chronic and progressive. 

Difficult conversations: how to have them

05 Sep 2017

In August, we sent an email about ‘difficult conversations’ with colleagues or friends.

We spend our whole day having difficult conversations with patients. We know how to break bad news, give advice that someone doesn’t appreciate, or talk about intimate and embarrassing things without a hint of awkwardness.

But, in reality, most of us find it hard to have a difficult conversation with a friend or colleague in which 'the truth is out there'. Having those difficult conversations is crucial to our wellbeing, and that of our practice, our staff, and ultimately our patients.

Whatever the issue in the conversation you need to have, or have been avoiding, if our previous email got you thinking, you might want to read on.

Helicobacter pylori eradication

30 Aug 2017

Advice to take 3 medications all at the same time to treat H. pylori infection may surprise or worry patients. But eradicating H. pylori has just become even more complicated! Due to concerns about growing H. pylori antibiotic resistance, we should take into consideration previous antibiotics prescribed to the patient.

NICE acknowledges that it is often difficult to establish a person’s previous antibiotic exposure, but, where possible, previous courses of clarithromycin, quinolones and metronidazole should be taken into account in decisions about treatment.

Healthy diet

23 Aug 2017

We regularly advise patients to lose weight or to eat a healthy diet. But when it comes to explaining exactly what this means, we may flounder. Many patients feel bewildered by dietary advice that seems to change from year to year, or find it difficult to translate into real-life choices. What does '30g of fibre per day' mean? And '<30g saturated fat'? The 'Eat Well Guide' was launched by Public Health England in 2016 to update the dietary recommendations in the 'Eat Well Plate'.

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.
MATT

Join our FREE mailing list for Latest Updates

Job Title
Are you interested in:

Updates for GPs
Updates for Nurses

Update my subscriber profile