Latest Updates - 'Pearls' from the Red Whale

I can recall when a late visit request came in 5 minutes after I had been called by the childminder to pick up my daughter urgently. In that instant, in full ‘fight or flight’ mode, I was only able to focus on the logistical nightmare ahead of me. I was not the empathetic, kind or safe doctor that I wanted to be. Luckily, I realised in time to change my behaviour and focus on the clinical problem in front of me. But there are numerous times when I might not have behaved in the manner I would aspire to due to the stress of time pressure, workload, uncertainty and the plethora of other challenges that we encounter on a daily basis.

So, what strategies can we use to manage stress and increase our personal resilience? This article on resilience from our LMT! handbook may give you some strategies.

You can also listen to Dr Rachel Morris (co-author and presenter of the LMT! course, and Director of Leadership Courses at Red Whale) talking about her take on resilience on this podcast from Ockham Health. 

Why not spend some time focusing on your own personal resilience this month? Not only will it help you live and feel better, but it will also increase your clinical effectiveness and help you thrive at work.

Click below to see the article on resilience from our Lead. Manage. Thrive! Handbook.

The authors of the study concluded ‘it is unlikely that GPs can identify older patients at highest risk of cold-related death using routinely available data and NICE may need to refine its guidance’. We agree!

Click below to see our summary of this NICE guidance but also much more to help you review and manage your patients with multimorbidity, frailty and polypharmacy.

Find out more at: Older people>Multimorbidity, frailty and polypharmacy.

There is a triad of the following in about 60% of patients:
1. Gait and balance disturbance.
2. Cognitive impairment.
3. Urinary incontinence.
The symptoms progress over a period of at least 3m, and only some of the triad may be apparent on initial presentation. If we do not think about it, we will miss it.

Click below to see our summary of a 2016 BMJ article on idiopathic normal pressure hydrocephalus from its ‘easily missed’ series.
 

These are encouraging results and we should be promoting this to our patients.
However, with the way the vaccination programme is being rolled out, it can be confusing to know who is eligible and when. The PHE shingles eligibility calculator may help patients (and clinicians!) work out who is eligible. We have included a link to this in our article. 

Click below to see our summary of this 2018 Lancet Public Health paper which looked at uptake rates of the shingles vaccination and the incidence of shingles and post-herpetic neuralgia in England.
 

Alternatives to HRT include non-pharmacological and pharmacological treatments.

• Complementary and alternative medicines, including herbal preparations, have a limited evidence base. 
• Evidence suggests that CBT and hypnosis may be beneficial, but mindfulness and relaxation therapy are not. SSRIs/SNRIs, gabapentin and clonidine may reduce vasomotor symptoms, but these are not recommended first line by NICE.

And remember to avoid paroxetine and fluoxetine in women on tamoxifen.

We have summarised a recent BMJ clinical update which discusses the relative merits of the alternative treatments available, including pharmacological and non-pharmacological options.

Click below to see our summary of this 2017 BMJ update and NICE guidance on alternative treatments for menopausal symptoms.
 

Myeloma is rare, and early diagnosis improves survival. But, it is a difficult one for us to spot. Of all cancers, myeloma has:

•    The longest interval between first presentation of symptoms and diagnosis, with a third of cases taking more than 12 months to diagnose.
•    The greatest number of primary care consultations before diagnosis.

The bottom line is that individual symptoms of myeloma in primary care are generally low risk, and that is why there is diagnostic delay. We need a high degree of suspicion and need to take appropriate blood tests. This increases the probability of making the diagnosis.

In this PEARL, produced in association with Macmillan Cancer Support, we discuss what symptoms should raise our suspicions, which tests we should do, and the NICE guidance for referral and management. 

Click below to see our summary of several BMJ and BJGP articles, and NICE guidance on myeloma.  
 

• Vaping is thought to be associated with a fraction of the risks of smoking:
  - Vaping is estimated to be 95% less harmful than smoking.
  - The risk to bystanders is thought to be negligible.
  - The cancer risk associated with vaping is quoted as less than 0.5% of the risk associated with smoking.
   
• Changing from smoking to vaping gives substantial health benefits. E-cigarette use is associated with:
  - Improved quit success rates (use associated with up to 20 000 successful new quits/y).
  - An accelerated decline in smoking rates in the UK.

There have been concerns in the past that e-cigarettes may encourage young people to start smoking; this report did not show this association.
In view of these findings, PHE is keen to ensure current smokers are correctly informed regarding the risks of conventional smoking vs. e-cigarettes. PHE advocates promoting e-cigarette use in current smokers.

This report brings welcome clarity regarding the use of e-cigarettes. While we cannot reassure our patients that e-cigarettes are safe, we can tell them that e-cigarettes are probably much less harmful than continuing to smoke.

Click below to see our summary of a 2018 PHE report and recent BMJ articles on e-cigarettes.
 

Infection can occur by ingestion of oocysts from faecally-contaminated water, person-to-person transmission or animal-to-person transmission. So, risk factors include: drinking contaminated water; swimming (including in swimming pools) or water-based recreational activities; contact with animals (especially young ruminants) and dung; contact with infected individuals; and travel to less-developed countries.

Children under the age of 5 are at increased risk, especially those at nursery. Adults who change young children’s nappies/help with toileting are also at increased risk, even if the child does not have diarrhoea! This is due to asymptomatic carriage.

In the UK, cryptosporidium is only a notifiable disease if it is believed to be food- or water-borne. It is not a notifiable disease if caught by person-to-person transmission.

Click below to see our summary of a 2017 BJGP review and an older BMJ article on cryptosporidium.
 

There is 5-fold increased risk of invasive skin conditions with NSAID use, though the absolute risk of severe skin infection is low (about 3/1000 cases). These and other studies can only demonstrate an association, but they seem a sound basis on which to recommend that NSAID use is avoided during attacks of chickenpox.

Interestingly, the NICE CKS on shingles actually recommends NSAIDs in adults (but NOT in children). Why? Possibly because the relative risk increase is only 1.6 on a background risk of 6/1000, so the absolute risk increase is small.

Paracetamol is safe in standard doses.

Take home message: in children with chickenpox or shingles, do NOT recommend or prescribe NSAIDs for pain relief or fever. In adults, do not use NSAIDs in chickenpox. 

However, it is worth remembering that many parents manage chickenpox without seeking medical advice, or might just seek advice in a telephone consultation. Do we need to think about how we get this message across to patients?

Click below to see our summary of the NICE CKS recommendations and the studies that these were based on.
 

NICE 2015 and SIGN 2017 criteria for diagnosis of gestational diabetes after a 75g glucose load:

Units are mmol/L, and any single blood sugar above these levels is diagnostic.

You might need to check which criteria your local maternity service is using for diagnosis of gestational diabetes.

Do also note that Lucozade now has a lower sugar content and is no longer suitable for use in oral glucose tolerance tests. The BNF lists Rapilose OGTT solution (glucose 250mg per 1ml, drink 300ml for a 75g glucose load) as an appropriate formulation.

Click below to see our summary of the NICE and SIGN guidance on gestational diabetes.

Not all acute dizziness is labyrinthitis (vestibular neuritis); indeed, this is rarely the cause. Patients with vestibular neuritis will have lost their vestibulo-ocular reflex on one side – the reflex that allows you to fix your gaze on a point even if your head is moving. This reflex can be tested with the head thrust test. 

Ménière’s and cerebellar stroke are rarer causes.  Read the full article (just over a page in length) and, next time your patient tells you they are dizzy, you should feel more confident in making the correct diagnosis.

For those with chronic dizziness, a simple booklet with exercises can make a substantial difference to their symptoms.And, if you come across a script request for betahistine, you may want to think twice before signing it…

Click below to see our summary of the features of each of these conditions which cause vertigo, along with an explanation of the head thrust test.

We have also included two further summaries for your summer holiday reading! One looks at rehabilitation exercises for chronic dizziness/vertigo and the other looks at Meniere’s disease and the evidence for betahistine.
 

Your patients may well be using such substances. They may cause side-effects or harm, and your patients may want or need to stop using them. There may be withdrawal effects with some. 

Click below to see our summary of a 2017 BMJ paper which looked at how primary care clinicians could identify and offer help, if wanted, to those using these drugs.
 

Targeted treatments, including immunotherapies, offer real hope for carefully-selected patients. Annie has been fortunate to respond to treatment as, despite careful selection, some patients respond to targeted therapies while others do not. Undergoing treatment and managing the subsequent side-effects has been very disruptive and difficult for Annie and her young family. However, she remains positive. She readily tells how grateful she is for her treatment, despite the troublesome side-effects, because it has been so dramatically successful. She is well aware how poor the outlook was without this treatment.

Immunotherapy is now quite widely used to stimulate the body’s own immune system to fight diseases. Targeted and gene therapies are based on advances in mapping the human and cancer genome. Research is ongoing, and this is a rapidly changing field.

Despite the targeting of cancer cells, side-effects can be very troublesome with the new therapies. Side-effects vary from therapy to therapy, and patients should be fully informed by the initiating team about side-effects and what to do if they develop. However, we may end up participating in shared care arrangements, or be put on the spot with an awkward question! This is particularly an issue because side-effects can occur 6–12m after treatment has finished – a real pitfall for us in primary care.

In our summary, we consider the frontiers of cancer treatment: immunotherapy, targeted therapies and gene therapies. We need to know a bit about them because they are becoming more common and we may be the first port of call in the event of side-effects.

This week, our Pearl is again produced in association with Macmillan Cancer Support along with information from Cancer Research UK. We have summarised the main things we think GPs may find helpful to understand about this exciting and rapidly-developing new mode of cancer treatment.

Click below to see our summary of: a 2016 BMC Medicine review article, information from the websites of Macmillan and Cancer Research UK, and some drug SPCs.
 

Consider the more common life-threatening causes of fever in returning travellers: malaria and enteric fever. But remember that travellers also get ‘normal’ illnesses, so you should not forget influenza, pneumonia, UTI, etc. Look for signs of sepsis, markers of severity (vital signs), focus of infection (chest, jaundice for hepatitis), rash or eschar (looks like a scab but is full thickness). Management usually involves hospital referral for further testing/treatment.

Click below to see our summary of a 2017 NEJM review of diseases that travellers might return with.
 

The authors concluded that this study demonstrated a viable treatment option for adolescents with CFS/ME, and supported wider implementation – this is now happening within the context of a clinical trial in the UK.

FITNET–NHS is a randomised trial based at the Royal United Hospital in Bath, in association with Bristol University. It is aiming to recruit more than 700 adolescents. Subjects will be randomised to receive either FITNET (19 online psychoeducation modules) or Activity Management (the NICE recommended treatment strategy) – there is no placebo arm.

These interventions can be delivered at home – no visits to Bath are required, and GPs across the UK can refer to this service (although the diagnosis does have to have been confirmed by a paediatrician). We think this is a good opportunity for teenagers with this difficult diagnosis. 

Click below to see our summary of the Lancet 2012 article, details of the eligibility criteria and how to refer your patients to the FITNET-NHS trial, which is recruiting until May 2020.

Faltering growth is defined as:

• Birthweight below 9th centile: a fall across 1 or more weight centile spaces. 
• Birthweight between 9th and 91st centiles: a fall across 2 or more weight centile spaces.
• Birthweight above the 91st centile: a fall across 3 or more weight centile spaces. 

Faltering growth is usually multifactorial and due to inadequate nutrition. Physical causes account for <10% of cases and neglect for <5%, but we must consider these possibilities. NICE suggests we also consider investigating for UTI and coeliac disease in primary care. We should offer feeding advice (or refer to health visitors for this). 

Refer for further assessment and possible investigation if there is suspicion of an underlying condition, poor linear growth, or failure to respond to primary care measures.

Click below to see our summary of 2017 NICE guidance and a helpful 2012 BMJ review of faltering growth in children.

The three best discriminatory features are:
1.    Any trouble putting on socks? (in which case, it is more likely to be osteoarthritis.)
2.    Pain on palpation around greater trochanter (lack of pain makes greater trochanteric pain syndrome unlikely).
3.    Single leg standing on affected leg gives pain within 30sec (more likely to be greater trochanteric pain syndrome).

A positive result on the combination of these last two tests (pain on lateral palpation and on single leg standing) makes greater trochanteric pain syndrome very likely. Rest, then specific exercises, are the mainstay of treatment.

Click below to see our summary of a 2017 BJGP review of greater trochanteric pain syndrome and a 2018 BMJ study comparing treatments.

About 1 in 20 people have a hypopigmented lesion. Most are not caused by serious pathology but they can cause significant worry, especially in darker skins.

Common causes include vitiligo, post-inflammatory changes and pityriasis versicolor, but there are also a number of rarer causes. Most of the common causes are diagnosed clinically. Age, distribution of lesions and other associated skin changes can guide our thinking about the cause of the hypopigmentation.

We should remember to also consider the psychological impact.

Click below to see our summary of a BMJ article from 2017 looking at how we should approach hypopigmentation.

The statistics around pancreatic cancer make disturbing reading: 10 000 new cases of pancreatic cancer are diagnosed each year in the UK. It has the worst 1y survival rate of any cancer. It is the 5th most common cause of cancer death, despite being the 11th most common cancer. Only 10% of cases will be resectable at the time of presentation.

Painless jaundice, the classic presentation of pancreatic cancer, is usually a relatively late symptom.

Our difficulty is that pancreatic cancer is easily missed because its symptoms can be vague and varied. Initial presenting features are often non-specific and are common to many other conditions which present in a similar age group, for example back pain or abdominal pain. To diagnose it early, we need a high degree of suspicion. Key points from the ‘top tips’ for GPs produced by Macmillan Cancer Support and Pancreatic Cancer UK include:

Consider pancreatic cancer:
•    In patients with new onset diabetes, especially if aged over 60 or if previously stable diabetes suddenly becomes unstable.
•    If conditions such as GORD, gallstones, IBS, hepatitis or pancreatitis are not improving with treatment.
•    In new-onset mechanical back pain associated with gastrointestinal symptoms.
•    In repeated consultations for GI symptoms that are not resolving.

CT is the gold standard investigation for suspected pancreatic cancer.

NICE 2018 guidance highlights the ongoing need some will have for nutritional support, including pancreatic enzyme supplements. It also recognises the importance of psychological support where there are ongoing gastrointestinal symptoms, fatigue and pain. It notes that coeliac plexus block may be considered where pain management is complex. 

This week, our Pearl is produced in association with Macmillan Cancer Support and Pancreatic Cancer UK. As well as diagnosis and management, it looks at risk factors, genetics, screening for familial pancreatic cancer and tumour markers.

Click below to see our summary of: 2018 NICE guidance on the diagnosis and management of pancreatic cancer, as well as the 2015 NICE suspected cancer referral guidelines, along with articles from the Lancet and BMJ on pancreatic cancer, and ‘top tips’ for GPs from Macmillan Cancer Support and Pancreatic Cancer UK. 
 

Effective hair removal treatments remain important, though they are not widely available through the NHS.

Click below to see our summary of two clinical review articles on hirsutism from the BMJ. These consider when we should be concerned about an underlying problem, when and how we should investigate, and what treatments are available.
 

Antithyroid drug treatment is often used first line in the UK. Regular blood tests are needed. Relapse rates in Graves’ disease are 50–70%. We should give all patients starting antithyroid drugs written information about agranulocytosis. They must seek an urgent FBC in the event of sore throat or fever.
Radioiodine and surgery offer greater chances of cure but both have disadvantages. They are first-line options for toxic nodular goitre and solitary nodules.

A recent observational study suggests that even subclinical hyperthyroidism increases the likelihood of being diagnosed with atrial fibrillation, so we should remember to check pulses!

Click below to see our summary of 2 articles: a Lancet review and a BMJ clinical review on the diagnosis and management of thyrotoxicosis. 
 

If you think a patient has it, refer to dermatology for biopsy and confirmation – call to discuss!

Oral doxycycline is an increasingly evidence-based option, and may be used at the beginning alongside topical steroids.

Click below to see our summary of a 2017 clinical update on bullous pemphigoid from the BMJ, which incorporates guidance from the British Association of Dermatology.  
 

It is important that we are aware of the long-term consequences of treatment. Here, we pull together a number of re-sources to highlight the common concerns and issues that breast cancer survivors may experience. A recent BJGP review considered this (BJGP 2017;67:140) and highlighted the following key areas:
•    Menopausal symptoms.
•    Bone health.
•    Cardiovascular disease and cardiotoxicity of treatment.
•    Psychological problems.
•    Persistent pain.
•    Lymphoedema.

This week, our Pearl is produced in association with Macmillan Cancer Support. It looks at each of these areas, providing practical tips of how we can help in primary care.
 

It does not look as if Tariq has a minor sprain or strain, and, at the age of 19, osteoarthritis is unlikely! After fleetingly wishing Tariq had just gone to A&E last night, you start your evaluation. There are decisions to be made. But how do you distinguish a fracture from a meniscal injury. And what about the collateral and the cruciate ligaments. The knee is a complicated joint! 

The first thing to do is rule out a fracture or dislocation. The Ottawa Knee Rules have been well evaluated and will miss <1.5% of fractures. If we don’t suspect fracture or dislocation, we then need to assess the knee to determine the next steps. But this can be difficult in the acute setting where there may be pain and effusion, and reassessment in 10–14d may be appropriate.

While history tells us there might be internal derangement of the knee, examination may help us to spot where it is, but no single test has excellent performance qualities.

If considering referral, a 2017 NICE CKS is helpful for deciding when we should refer immediately, when to refer to an urgent OP clinic, or when a routine referral might be appropriate.

Click below to see our summary of a 2017 NICE CKS, a JAMA rational examination review and an Ann Int Med systematic review looking at the evaluation and management of traumatic knee pain.