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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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Lichen sclerosus

24 Apr 2019

Lichen sclerous is a chronic inflammatory skin condition affecting anogenital skin. It is most common in postmenopausal women but can occur in any age in men or women. It is strongly associated with autoimmune disease, especially thyroid problems which co-exist in 30% of patients. Squamous cell carcinoma is a well-recognised complication that may occur in up to 5% of sufferers, so surveillance is required.

Lichen sclerosus was considered as part of the BMJ Easily Missed series. The authors suggest that the most common reason it is missed is because of failure to examine the genital skin, or misdiagnosing it as candida or atrophic vaginitis.

Investigation of bruising

16 Apr 2019

"I have these bruises on my legs and I'm sure I've knocked against anything", Robyn says pointing to her lower legs. "The bruises seem to just come up by themselves. I've googled it and I'm worried I might have haemophilia or leukaemia."

A 2017 BMJ article on investigation of bruising covered common as well as rarer causes, an approach to history and examination, and recommendations regarding investigations, management and when to refer.

Epilepsy and antiepileptics in pregnancy

10 Apr 2019

Epilepsy is a common condition which can cause concerns in pregnancy due to perceived risks of medication use. Antiepileptic medications are associated with an increased risk of congenital abnormality. However:

  • 96% of babies born to women with epilepsy are healthy.
  • Most women with well-controlled epilepsy will not experience a worsening in seizure control during pregnancy.

HPV vaccination – now it’s universal!

04 Apr 2019

In July 2018, the Joint Committee on Vaccination and Immunisation extended the HPV vaccination programme to adolescent boys. It commented that assessment of cost-effectiveness in the long term is complex, and decided to include boys in the HPV vaccination programme because:

Brain tumours

27 Mar 2019

Today is the third time Maria has come to discuss her headaches. "These headaches have been going on for so long. Why can I not have a brain scan? I am so worried." Patients' spoken, or sometimes unspoken, fears when suffering with headaches are around brain cancer as a possible cause.

Headaches are common in patients with brain tumours. They are reported in 10% of records of adults and 20% of records in children in the year before diagnosis. BUT headaches are very common in the general population. This makes the PPV of headache as a symptom very low - less than 1% even in combination wit other symptoms.

Clostridium difficile

21 Mar 2019

Clostridium difficile (C. difficile) infection usually occurs in patients whose normal gut flora has been disturbed by a course of antibiotics in the past 8 weeks. We should suspect the diagnosis  in anyone presenting with diarrhoea who has recent exposure to antibiotics.

It is most common between day 4-9 but can occur up to 8 weeks after the exposure.

Clindamycin, cephalosporins and quinolones are the main culprits in the community.

Contraception and depression

13 Mar 2019

Debbie, aged 19y, started on a COCP 3 months ago. She has come back asking to change her pill. "I have been so moody and that is just not like me", she says. "My boyfriend says that I am not my usual self. It must be the pill. I have never been up and down like this before."

The FSRH notes that recent observational evidence shows an association between hormonal contraception use and depression but does not prove causation. Also, that factors associated with being sexually active may contribute to mood changes rather than the contraception itself.

Coeliac disease

06 Mar 2019

If your practice is like ours, you will have seen many patients with gut symptoms, fatigue, headache, etc. who present having already removed gluten from their diet. They are convinced they have coeliac disease because they feel so much better. They are understandably reluctant to revert to a gluten-containing diet in order to secure their diagnosis.

So, how much toast do you need to eat and for how long? Current guidance is to continue a gluten-containing diet for 6 weeks before carrying out an IgA TTG, and to continue this diet while awaiting endoscopy, biopsy and histology. This is because the test may come back falsely negative if they are not on a gluten-containing diet.

Which is the best DOAC, and how do DOACs compare with warfarin?

28 Feb 2019

Bearing in mind that DOACs are still relatively new drugs and we have limited long-term safety date, is there evidence for any one DOAC being better than the others? Yes! Superiority of one DOAC over another is beginning to emerge, with the all-round winner probably being apixaban.

And, what about comparing DOACs with warfarin? DOACs offer some benefits over warfarin in terms of stroke prevention, but the benefits are not huge, and may disappear in older people (>75y). DOACs are probably associated with a higher risk of gastrointestinal bleeding but lower risk of intra-cranial bleeding when compared with warfarin.

Ask WHY before HOW

20 Feb 2019

It's official: we will all need to work in networks by June 2019!

But why? Because the government says we should and it's the only way to get any money might be what springs to mind, but that is hardly a satisfactory answer.

One of the key mistakes when thinking of 'working at scale' is a failure to understand why an individual practice might choose to do it. Without a specific task in mind or a problem that needs solving, may working-at-scale solutions can seem a bit like jumping on a band wagon 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.

Pancreatic cancer

14 Feb 2019

Barry retired 2 months ago, having recently turned 63. He prepared well for retirement, and has started working with a number of organisations he wishes to support in a voluntary capacity. Barry readily says that being able to spend more time with his grandchildren is what he has been most looking forward to in retirement. He had not felt unwell, though retrospectively realises that he had lost some weight. So, when he rapidly developed painless jaundice, it was a huge shock to discover that he has pancreatic cancer. His life, hopes and plans have been turned upside down.

Hypoactive delirium

06 Feb 2019

Mrs Jones, cherished and well cared for by her equally elderly husband, couldn't possibly have delirium as she is not agitated. For some days, however she has fluctuated from seeming to be her usual self to being quiet, withdrawn and sleepy. She "just does not seem to be there" at these times.

There are three subtypes of delirium:
 

       *  Hyperactive delirium is most commonly recognised and is associated with restlessness and agitation.

       *  Hypoactive delirium accounts for up to 50% of delirium and is characterised by being withdrawn, quiet and sleepy. IT IS EASY TO MISS!

       *  Mixed delirium - exhibits features of both hyperactive and hypoactive delirium.

Mild cognitive disorder – what’s that?

30 Jan 2019

Some people referred into memory clinics will come back with a diagnosis of mild cognitive disorder. What does this mean?

Mild cognitive disorder is cognitive impairment WITHOUT functional impairment. This is in contrast to dementia where there is cognitive impairment WITH functional impairment.

Mild cognitive impairment affects up to 20% of those over 65y. It is a risk factor for dementia, with 20–40% of those with mild cognitive disorder progressing to dementia over the next 3–10 years (compared with only 3% progression in those without any cognitive impairment). Having diabetes/prediabetes, metabolic syndrome or a low folate increases this risk.

Abnormal LFTs

23 Jan 2019

I am sure the scenario will be very familiar to you: mildly abnormal LFTs in a well person with no jaundice.

Does this person have known or suspected risky alcohol intake? Could it be a drug side-effect? Do they have risk factors for viral hepatitis? Could this be autoimmune hepatitis, or might it be non-alcoholic fatty liver disease?

How should we approach teasing this out?

DMARD safety

16 Jan 2019

Another evening, another batch of results from the lab. Mr Rahim’s blood results have several abnormalities highlighted. He has been on a DMARD for years and has had no significant changes with his regular monitoring tests until today. What do you do?

Though DMARDS are initiated in secondary care an require monitoring, shared care is increasingly the norm. There are three types, all with different risks, but ALL have increased risk of infection.

Gynaecomastia: working out the cause

09 Jan 2019

Pete looked shocked when I asked whether he might be using cannabis. “Can that cause me to grow these boobs?”, he asked incredulously. In men, excessive breast tissue has two possible causes:

1) Gynaecomastia: proliferation of glandular tissue, usually firm, sub-areolar swelling – due to hormonal changes.

2) Pseudogynaecomastia: proliferation of adipose tissue – due to obesity.

They can occur simultaneously. Clinically, it can be hard to tell which is which.

New year resolutions and familial hypercholesterolaemia

02 Jan 2019

The last day of 2018 and a BBC headline reads: "Minority take up 'life-saving' free health check".

The article goes on to quote the national clinical director for dementia and older people's mental health for NHS England saying that the start of a new year was the right time to commit to "taking a simple, free and potentially life-saving step towards a healthier life".

With the new year resolutions to have 'a healthier life' you may have more patients requesting NHS health checks and see more blood test results coming in.

Sinusitis and sore throats

19 Dec 2018

'Tis the season to be jolly. It is also the season for misery with sore throats and sinusitis.

We have included these two common primary care ENT conditions in several previous updates. But, wait, there is more….

Sinusitis: the 2017 NICE guidelines suggest:

Contraception for adolescents with disabilities

12 Dec 2018

It can be challenging enough to navigate the way through adolescence (for adolescents and those who parent/support them). But for young women with disabilities, it can be even more complicated when it comes to managing contraception and pubertal issues.

The onset of menstruation in those with physical and mental disabilities can cause significant distress and distribution. Menstruation can exacerbate pre-existing chronic conditions (e.g. seizure control may worsen just before or during a period).

Adolescents with chronic conditions are as likely as adolescents without medical problems to become sexually active. However, they are significantly more likely to experience sexual abuse.

Lymphoma

03 Dec 2018

John was referred to the DVT clinic for his swollen leg. There was no sign of DVT, but further investigation determined that the venous obstruction was due to pelvic lymphadenopathy. John was diagnosed with lymphoma.

Lymphoma is the 6th most common cancer in the UK.

  • Non-Hodgkin lymphoma accounts for 90% of all lymphomas, mostly age >60y.
  • Hodgkin lymphoma has a bimodal age presentation with 2 peaks: age 20-24y and age 70-79y.

Contraception and weight

28 Nov 2018

Women are often concerned about the impact of contraception on their weight. The evidence base is imperfect and limited. The FSRH released helpful statements in 2017 and 2018 regarding contraception and weight.

Key points are:

Chronic pancreatitis

22 Nov 2018

What is it?

Chronic pancreatitis is a rare, incurable syndrome characterised by inflammation and fibrosis of the pancreas. There is loss of exocrine and endocrine tissue, and therefore loss of exocrine and endocrine function.

What causes it?

  • Alcohol (this is a cause in 60% of chronic pancreatitis in men but only 28% in women, for whom it is more likely to be idiopathic).
  • Smoking (thought to be equally as risky as alcohol).
  • Genetic mutations (these also increase the risk of secondary pancreatic cancer).
  • Autoimmune pancreatitis.
  • Idiopathic.


Other risk factors include obesity and longstanding diabetes.

Antiphospholipid syndrome – a reminder!

14 Nov 2018

A review of antiphospholipid syndrome was recently published in the NEJM. If you are anything like me, you may well be struggling to recall any details about antiphospholipid syndrome. So, here is a reminder.

What is it?
It is a systemic autoimmune disease which increases the tendency for thrombosis and adverse obstetric events.

Resilience – why does it matter?

07 Nov 2018

Resilience is a concept that many people struggle to define. However, evidence shows us that many of the elements that make up a ‘resilient’ mindset are key to good clinical practice, making good decisions and minimising error. In times when things seem to conspire against us to make our jobs harder and harder, focusing on our personal resilience should be a priority rather than something left until we have enough time.

Resilience has been defined as ‘adaptability’ or ‘the capacity to recover quickly from difficulties’. I have also heard it described as ‘resourcefulness’ or even ‘mental toughness’. It is often seen as a soft skill and we may have become cynical, observing that resilience seems to be the answer to all the problems currently facing General Practice. However, resilience is anything but soft; we can all probably think of times at work when our clinical decision-making was affected by stress, fatigue or mental exhaustion.

Multimorbidity: frailty and cold weather!

01 Nov 2018

The 2015 NICE guideline on excess winter deaths suggested that primary care team members should, in collaboration with other relevant authorities, identify people who live in cold or hard-to-heat homes.

A recent case-crossover analysis of more than 34 000 deaths assessed if there was any correlation between death and the average 3-day temperature at the time. It reported a statistically significant association between a lower 3-day temperature and risk of death (OR 1.011 per 1-degree Celsius fall (CI 1.007–1.015)). However, this tiny increased risk is highly unlikely to be clinically significant!