Latest Updates - 'Pearls' from the Red Whale

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.  
 

“Our practice recently joined a Federation. It sounded like a good idea – on paper. We thought it would give us greater ‘clout’ with the commissioners and the local acute care trust. Each practice put quite a bit of money into it; the CCG was very supportive and even chipped in as well. It’s now a year down the line and nothing seems to have happened apart from the formation of a Board and a ‘branding exercise’. Frankly, we’re wondering why we bothered….”

One of the key mistakes we have seen when practices are thinking of ‘working at scale’ is a failure to understand why an individual practice might choose to do it. Without a specific task or a problem that needs solving, many working-at-scale solutions can seem a bit like jumping on a bandwagon that’s heading off to nowhere. 

Once you understand WHY you might need to work at scale, you’ll be able to understand much better HOW you should go about doing it. There are many options out there, and it’s crucial to understand which one is just right for your practice.

So, you need to be clear about what problem you are trying to solve. You might try reframing the problem to come up with more creative solutions. Working at scale isn’t an end in itself – it’s a strategy. You must start with WHY you want to work at scale, not HOW or WHAT.

Click below to see our article ‘Ask WHY before HOW’ from our brand-new Working at Scale course. 
 

When NICE issued its referral guidelines for suspected cancer, the use of a raised platelet count as a marker for lung, endometrial, gastric and oesophageal cancer came as a surprise to many of us. We suggested you remember them as the LEGO cancers. Now, a large UK prospective primary care-based study of more than 50 000 adults aged 40y or more has produced striking results. 

Raised platelets in those over 40y are strongly predictive of a new cancer diagnosis in the next 12 months, including colorectal cancer. One-third of patients with raised platelets who had a diagnosis of lung or colorectal cancer had no other symptoms. The higher the platelet count, the greater the risk. Two raised platelet counts in a 6m period are even more predictive. Thrombocytosis is also predictive of colorectal cancer. We have changed LEGO to LEGO-C. 

So, think very carefully if you see a raised platelet count in an adult aged 40 or older – could this be cancer?

We are teaching this in our summer GP Update courses (along with lots of other great topics). But since we received such amazing feedback, we thought it would be useful to share it with every GP, not just our delegates.

Click below to see our summary of a 2017 BJGP article looking at thrombocytosis and cancer, and why not watch the video to hear our GP Update presenters Nik and Charlotte explain in more detail. 

She will need progesterone as well as oestrogen. But, what do you recommend about conventional or conjugated equine oestrogens? What if she asks about plant-based ‘bioidentical’ hormones? What about progestogenic side-effects and micronised progesterone? If Chloe reports that low libido is adding to her woes, is there evidence that tibolone might be a better option? And, what about bazedoxifene, a selective oestrogen receptor modulator which acts as an oestrogen receptor antagonist and is included in the new HRT preparation Duavive?

It can be very confusing trying to choose an appropriate treatment from the myriad of different HRT formulations listed in the BNF.

To help your discussion with Chloe, our article discusses the properties of the following HRT preparations:
•    Conventional (oestradiol and progestogen-based) formulations.
•    HRT containing conjugated equine oestrogens.
•    Duavive.
•    ‘Bioidentical’ hormones.
•    Micronised progesterone.
•    Tibolone.

Click below to see our summary of information from the BNF, a Cochrane review, a NICE evidence summary, and various other articles on HRT. 
 

But ‘chemotherapy’ is a collective term used to cover increasingly complex and diverse medical treatments for malignancy. Most patients having chemotherapy will be given a complex regime of treatments. This will usually be as an outpatient, but is increasingly at home. The use of oral chemotherapy agents and immunotherapies has made things even more complicated. There is a risk that patients taking oral preparations may not even be aware that they are having a form of chemotherapy. And we might not spot this either!

In addition. the newer therapies can be associated with significantly delayed side-effects up to 12 months after treatment stops. This is a potential pitfall when patients attend primary care with undifferentiated symptoms. They may not realise that their symptoms are a sign of delayed toxicity. For example, what about the patient that had immunotherapy 9 months ago and has abdominal pain and diarrhoea – did you know that treatment-related colitis can occur up to 12 months after treatment has finished? 

Our Macmillan PEARL this week focuses on spotting oncology emergencies in primary care. It is important we know where to get good quality information.

Recognising this changing and challenging situation, Macmillan has worked with the UK Oncology Nursing Society (UKONS) to produce a tool for primary care teams to help us recognise and safely manage immediate and delayed toxicity symptoms of chemotherapies/immunotherapies. The tool uses a traffic light table for quick reference. It can be used as a structured way of quickly checking for other symptoms the patient may not have mentioned.

The key message is that for almost all symptoms, phoning the 24-hour helpline is the most important and appropriate course of action.

You can find a link to this tool below – feel free to print it out, laminate it and share it with your colleagues. 

We will also be hosting our first Macmillan Webinar on 15th May where you can hear more about the UKONS tool and acute oncology. This is a great opportunity to ask our Course Director, David Plume, and Richard Simcock, Consultant Clinical Oncologist, everything you ever wanted to know (well, about acute oncology!). Feel free to send those questions ahead of time to mail@red-whale.co.uk.
 

Aetiology is different depending on whether the leg (70% venous insufficiency) or the foot (85% neuropathy) is affected. Anyone with a suspected arterial ulcer should have an ABPI. It is good practice to do ABPIs on all patients with venous ulcers/varicose veins before considering compression treatment because of the possibility of mixed arterio-venous aetiology of the ulcer.

A 2017 NEJM review of leg ulcers gives succinct advice about dressings, although most CCGs have a local prescribing formulary for dressings which is based on cost-effectiveness, and this is what we should follow. It reminds us that spotting which ulcers are infected, as opposed to colonised with skin commensals, can be difficult. Suspicion of infection should be determined clinically, and swabs should only be used to guide antibiotic treatment. 

The review defines successful treatment and expected rate of progress over 4 weeks as being:
•    30% reduction in venous leg ulcer. 
•    50% reduction for diabetic foot ulcer.

But other questions arise as well. Is there a place for antiplatelet drugs? And what about pentoxifylline?

Click below to see our summary of this 2017 NEJM review, relevant SIGN guidance, and other recent articles on the diagnosis and management of leg ulcers. Our summary includes a helpful table which guides us to spot the most likely type of ulcer for any given patient. 
 

In trials, Z-drugs reduced  the time to getting off to sleep by only 22min (CI 11–33min) compared with placebo. This minimal benefit is worth sharing with patients. 

• Benzos and Z-drugs are addictive and may cause daytime sleepiness - the DVLA rules on driving and drugs apply to all these agents.
• We should warn patients that one of the problems with next day driving impairment is the lack of awareness of a problem! 
• We should also be aware of the new US and European guidance on zolpidem doses in women. 
• NICE guidance restricts the use of the Z-drugs and benzodiazepines to those with severe insomnia which has a significant impact on everyday life.

But the good news is that there are valid alternatives.

• Sleep hygiene will help all, and for some this will be all that is needed. For those with primary insomnia (no underlying cause), 30% will get better with sleep hygiene alone. 
• Cognitive behavioural therapy for insomnia, called CBT-I, is consistently better than any drug therapy in chronic insomnia for both effectiveness and long-term benefits. 
• CBT-I combines sleep hygiene, stimulus control, sleep restriction, relaxation training and cognitive restructuring. 

• CBT-I should be available through IAPT, or patients can purchase it themselves; it costs just under £100.

Click below to see our summary of a BMJ clinical review that looked at some of the causes of insomnia and some treatment strategies. We have also included information from a review in the NEJM and another BMJ review.

Menopause is a normal physiological event. In the UK, the average age for a woman to reach the menopause is 51y. Declining oestrogen levels cause menopausal symptoms. HRT is the most effective available treatment for vasomotor symptoms.

We need to know more about Chloe. Is she still menstruating? If not, is it more than 12m since her last bleed? Has she had a hysterectomy? Is she using an IUS? Does she have any contraindications to HRT? If Chloe decides to go ahead with HRT, she will need advice about what formulation might best suit her. And what about possible side-effects, monitoring, duration and stopping – what advice will Chloe need about these?

Click below to see our summary of British Menopause Society recommendations from 2016, NICE guidance from 2015, the BNF, and a therapeutics article from the BMJ.
 

These articles have included tragic stories of how prescriptions for pain relief have led to addiction, with all its destructive consequences. Some, with deep honesty, reveal how GPs were manipulated into continuing to prescribe or to prescribe increasing doses. Some highlight how easy it is to access opiates over the internet. Personal, individual stories of the devastating toll that addiction can have on relationships, family, work.

And, for us, the reality behind the headlines….

A few days ago, one of our receptionists handed me two pieces of paper for a newly registered patient, saying that ‘Jane’, aged mid-30s, was housebound and couldn’t come in for an appointment, but needed a new prescription by Monday. One piece of paper was a letter from a consultant about Jane’s chronic pain, saying that she had been referred for physiotherapy with the expectation this would help, and that she would be reviewed in 6 months. There was no mention of pain medication.

The other piece of paper was a handwritten list of medications needed on prescription, including huge doses of oramorph, codeine and gabapentin. A request for a faxed summary from Jane’s previous GP confirmed that she has been prescribed all these medications. Almost certainly, we have two big issues to help Jane with: managing her chronic pain, and managing what is likely to be opiate dependency.

So, how can we help patients with chronic pain. How can we avoid escalating prescribing and creating addiction? What are the better options for management of chronic pain? How can we help those, like Jane, already trapped in chronic pain and addiction?

There have been a number of articles recently in the Lancet, the BMJ and JAMA looking at the problem of opiate prescribing in non-cancer chronic pain (it is massive!), and reviewing the management of chronic pain. The Royal College of Anaesthetists has produced a helpful resource, Opioids Aware. The JAMA article reviews CDC guidelines for prescribing opiates in chronic pain.

In short: 

• Opiates are minimally effective in non-cancer pain. We have overestimated their benefits and seriously underestimated their risks.
• The key message is whenever possible, don't start opiates. We should broaden our approach to chronic pain- the drugs don't work for most. If we do prescribe, we should avoid high risk doses.
• We should think about opioid dependence in those for whom we are prescribing opiates.

And what about pentoids? The Advisory Council on the Misuse of Drugs (ACMD) feels that pregabalin and gabapentin present a similar risk of addiction and harm to that of tramadol.

Click below to see our summary of these articles and resources on chronic pain and opioids.