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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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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.

There is a significant risk of developing hypertension later in life if there has been hypertension in pregnancy

12 Feb 2018

About one-third of women with hypertension in pregnancy (gestational hypertension, pre-eclampsia, eclampsia or HELLP syndrome) develop hypertension in later life, and it can present as soon as 1y after delivery.

Obesity is the main risk factor, and modifying lifestyle to reduce weight will reduce the risk of developing hypertension in later life.

Perianal abscess. Is there a place for antibiotics?

05 Feb 2018

Harry, aged 43y, is too uncomfortable to sit. He tells you the pain in his anus that prevents him from sitting has progressed over the past 2 days. He has never had anything like this before and is desperate for something to be done. On examination, he has a tender, red, localised swelling lateral to the anus. You are confident that this is a perianal abscess.

Do you:
a.    Prescribe antibiotics and advise him to return if it is not settling?
b.    Take him to your treatment room and incise and drain the abscess?
c.    Refer him to your surgical colleagues for incision and drainage? 

Aspirin in TIA

31 Jan 2018

It is Monday. Noreen is the fifth patient on what is looking like a long afternoon list. She did not think she should bother the out-of-hours doctor when she had an odd experience of one-sided facial drooping and arm weakness on Saturday because it seemed to fully recover that same morning. You agree that you will refer her to the TIA clinic for further assessment. But should you start her on aspirin while waiting for the appointment later in the week?

Screening for cancer after unprovoked VTE

25 Jan 2018

Unprovoked VTE may be the first presentation of an occult cancer, and is particularly associated with breast, colorectal, urological and lung cancers. NICE guidance recommends investigation of patients presenting with a first unprovoked event, including, for certain patients, consideration of abdomino-pelvic CT. However, a BMJ review of the evidence for screening after unprovoked VTE confirms that the rate of cancer diagnosis in the following year is much lower than previously thought.

Travellers’ diarrhoea

17 Jan 2018

There are many ways in which Asia is gloriously different! But there is one rather less glorious difference that you need to remember. For travellers to South East Asia and South Asia, if you are considering prescribing prophylactic antibiotics for travellers’ diarrhoea, use azithromycin instead of ciprofloxacin or norfloxacin.

Ischaemic colitis: a diagnosis to consider in abdominal pain with bloody diarrhoea

08 Jan 2018

John, age 79y, has been fitted into your afternoon list as an emergency appointment. Through the morning, he developed moderately-severe, colicky-type abdominal pain. He became alarmed and called the surgery when he then had several episodes of bloody diarrhoea. On examination, he has quite localised abdominal tenderness but no sign of peritonitis. What is your differential diagnosis?

Hereditary haemochromatosis

04 Jan 2018

Early symptoms are non-specific, so if we do not think of it we will miss it. Fatigue is the commonest symptom. Others are: arthralgia, abdominal pain, weight loss and erectile dysfunction. So, very non-specific!

If you suspect the diagnosis, measure serum ferritin and transferrin saturation. But remember that ferritin can also be raised in acute or chronic inflammation, chronic alcoholism, liver disease, renal failure and cancer. Transferrin saturation is increased early in the illness and is more specific than ferritin. 

DVT in pregnancy

12 Dec 2017

In pregnancy, the risk of DVT/VTE is about 4× higher than in non-pregnant women. The majority of DVTs are left sided, due to uterine compression of the left iliac vein. Symptoms for DVTs in the leg are similar to those in non-pregnant women. However, there is an increased risk of pelvic DVT (usually left iliac vein) which may present as lower abdominal/pelvic, back or buttock pain.

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 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.