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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.

Leg ulcers

18 Apr 2018

Leg ulcers are common. They can have a profound impact on a patient’s quality of life. They also have significant impact on clinical services. Up to 50% of leg ulcers and 30% of foot ulcers are not healed at 6m (that is a lot of treatment room or district nurse visits!).

Lots of questions may arise in diagnosing and managing leg ulcers: what is the aetiology, is compression appropriate, is there any infection present, is the ulcer healing at an appropriate rate, when should we refer to specialist services?

Insomnia management: something better than a drug?

10 Apr 2018

Do you find managing insomnia challenging? Managing patient expectations can be even trickier! We hope this PEARL helps us and our patients make decisions around this difficult issue.

In primary insomnia, Z-drugs and benzodiazepines do work better than placebo, BUT, the effect is not long lasting and there are significant concerns about side-effects. Key things to be aware of:

HRT: starting, stopping and troubleshooting

04 Apr 2018

HRT can be bewildering for patients…and for us! Oestrogen-only, sequential combined, continuous combined, gels, pills, patches, pessaries, and where does the IUS fit in?

Chloe, aged 49y, says she has finally come to you as she can no longer bear the hot flushes; they are troublesome at work and disturb her sleep, leaving her exhausted and at her wits end. She has read about HRT and wonders whether this would be helpful for her.

Chronic pain and opiates

22 Mar 2018

In recent days, the media has focused on the issue of opiate use and misuse. 

“NHS accused of fuelling rise in opioid addiction” was the headline following a BBC investigation. This has been picked up by other media outlets with headlines such as “Opioid prescriptions in England nearly doubled in 10 years”, and, more sensationally, “The Opioid Timebomb: How addiction to painkillers cost me my wife, my children, my home and my £150,000-a-year job.”

Spotting measles: Red Whale’s top tip!

20 Mar 2018

We are currently seeing a measles outbreak in the UK. Measles has been confirmed in 5 areas, and social media suggests GPs across the country are seeing cases. But would you spot it? 

This was a real DEN for the Red Whale Team, and was something we taught on our Autumn courses. For example, did you know that two-thirds of cases in the UK have been in individuals 15 years or older? Many of us haven’t seen a real case.

We hope you find this quick, practical summary of how it presents and what we should do useful.

PSA screening

13 Mar 2018

There has been a LOT of media interest in PSA testing in the past few weeks since Stephen Fry and Bill Turnbull ‘went public’ about their prostate cancer (March 2018). We have had a tsunami of PSA test requests. But it is very important to state that the evidence has not changed one jot!

There is no screening programme for prostate cancer because it does not meet the essential criteria. There is, however, a risk management programme, and men are entitled to ask for a PSA test if they have made an informed decision.

Colorectal cancer: finally, a test FIT for purpose?

08 Mar 2018

Colorectal cancer is a cancer really worth spotting early…and historically, this was really difficult in primary care. 

The way we diagnose colorectal cancer has changed beyond recognition over the past 5 years. This is due to both national screening programmes and changes in criteria for urgent referral.

NICE guidance in 2015 gave us much more clinical leeway in who could be referred along the urgent pathway, and surprised many by reintroducing faecal occult blood testing as a ‘rule-in’ test in specific clinical situations – to pick up an additional population which might be at risk.

TEAR model of grief: the ‘tasks’ of grief

08 Mar 2018

I am sitting in a departure lounge at Heathrow waiting for a flight that will take me to the other side of the world. Some days ago, my father-in-law died. Jim was 95. Though physically robust until the last few weeks of his life, dementia had taken its toll over recent years. Nevertheless, his underlying sunny and optimistic personality shone through to the end. We will join family in Auckland for a service to celebrate Jim’s life. I am sure that there will be tears, but there will also be many good memories shared. There will be laughter over reminiscences and stories retold. Reflections on what Jim meant to each of us as a father, father-in-law, grandfather, great-grandfather and friend.

Preventing recurrence of renal stones: what works?

27 Feb 2018

You can often spot renal colic in the waiting room from the end of the corridor – pacing, groaning, a truly miserable experience. There is no doubt that anyone who has had a single attack will be very keen to know what they can do to avoid another!

Here are some tips:

Can breastfeeding rates be increased?

21 Feb 2018

Evidence and common sense tells us that breastfeeding benefits mums and babies. And it is more environmentally sustainable than formula feeding. But many of us will know, both from personal experience and from supporting our post-natal patients, that it is not always easy. The decision about whether to breastfeed is affected by a range of factors. One of the key messages in a 2016 Lancet article is that success in breastfeeding is not the sole responsibility of the mother because the promotion of breastfeeding is the responsibility of our whole society.

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.