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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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Measles

21 Aug 2019

"Boris Johnson orders action to stop measles spread", was the BBC headline this week. This was followed by an article entitles "Why is the UK seeing a rise in measles cases?".

In the first quarter of 2019 there were 231 confirmed cases in the UK. The UK has lost its measles-free status, 3 years after the virus was 'eliminated' in the country. This follows on from 2018 when there was a marked increase in reported measles cases, with 991 confirmed cases in England and Wales compared with 284 cases in 2017. Grim reading!

“My HRT is out of stock – what can I have instead?”

14 Aug 2019

By the time you get to deal with the drug query list at the end of the day, you may not be on top form, and finding appropriate alternatives can send your brain into meltdown. I think there is a real risk of us giving someone the wrong thing - and if that is unopposed oestrogen to a woman with a uterus, that really matters!

Our Women's Health team has put together this amazing resource: a GEMS on HRT covering the key things you need to know. And on the back page is a wonderful table listing the main types of HRT and equivalents. Print a copy for every room in your surgery now!

We hope this will help you as you plough through the drug query list!

If you want to know more, click to watch our Deep Dives webinar on the menopause and HRT.

Cellulitis: how do you know it is cellulitis?

30 Jul 2019

Try the leg raise test to avoid overdiagnosis of cellulitis and unnecessary antibiotic treatment.

With the patient lying horizontal, elevate the affected leg to 45 degrees for 1-2 minutes.

The erythema of cellulitis persists, whereas erythema secondary to vascular causes will commonly fade.

A test to try next time you are assessing for possible cellulitis and considering prescibing antibiotics.

And if you do prescribe antibiotics.............

You think your patient has erythema migrans. Now what?

24 Jul 2019

Lyme disease-carrying ticks can be found all over the UK. And with this lovely warm weather, many of our patients (and hopefully us!) are taking to woodland areas for nice shady walks. Inevitably, we will see a whole host of bites, most of which will resolve without any medical intervention.

However, what if we see a rash suggestive of erythema migrans? This is usually a red, non-itchy, painless rash which may develop central clearing. It can appear any time from 3 days to 3 months after a tick bite, but most commonly occurs between 1-4 weeks.

Hydroxychloroquine and retinopathy risk – do you need to take action?

18 Jul 2019

Retinopathy due to long-term hydroxychloroquine may initially be asymptomatic but is sight threatening - and it is more common than previously thought!

The 2018 Royal College of Ophthalmology recommendations on screening advise baseine examination, then screening after 5 years on treatment (including fundal photography - so eye clinic referral). Those with additional risk factors (e.g. tamoxifen use or renal impairment) may need earlier screening.

Walking aids and osteoarthritis

17 Jul 2019

You've not noticed before, but as you observe elderly Mrs Kelly walk into your consulting room, you see that she seems to waft her walking stick in the air. It appears to give little support. You realise you have no idea how long she has had the stick. No idea where she got it from. And no idea whether or not it's the correct size for her!

Individuals with osteoarthrosis using a walking stick have less pain and better quality of life, so Mrs Kelly had the right idea when she accepted a walking stick her sister no longer needed.

To dip or not to dip: that is the question!

11 Jul 2019

The diagnosis of UTI in women is primarily clinical. If symptoms are highly suggestive of cystitis, we can treat without doing any further tests. Only arrange urine testing if there is diagnostic uncertainty, to guide antibiotic choice, or if there are signs of upper urinary tract infection. Always send an MSU before starting treatment in a patient with upper UTI symptoms. The aim of urine culture is to identify bacteria and sensitivity to antibiotics.

Dipsticks are not as sensitive as clinical symptoms at picking up UTIs. Only perform a dipstick to exclude or help confirm a diagnosis of UTI in a woman with minimal symptoms (e.g. if there are mild or ≤2  symptoms present).

Rashes and exposure to rashes in pregnancy

03 Jul 2019

There are two scenarios to consider here: a pregnant woman presenting with a rash; and a pregnant woman exposed to a rash, but currently asymptomatic.

There are four viral illnesses that can cause problems for the non-immune pregnant woman. Varicella and parvovirus (common in children in the UK), and rubella and measles (less common in the UK but should be considered).

Remember that pregnant women can also develop meningococcal septicaemia and other general and dermatological conditions in pregnancy. 

Obstructive sleep apnoea and snoring in children

26 Jun 2019

Snoring is relatively common in children and is usually a 'normal variant'. But, in a small number of cases, snoring may be caused by obstructive sleep apnoea.

The good news is that adenotonsillectomy will cure simple obstructive sleep apnoea in the vast majority of children.

Exploring night-time symptoms and asking about day-time impact (behavioural problems, irritability, etc.) along with ENT examination will help us determine which children have obstructive sleep apnoea.

Menopause: Non-HRT treatments

21 Jun 2019

HRT is by far the most effective treatment for menopausal symptoms and, where possible, should be our first choice. But it is contraindicated in some women and others do not tolerate it or prefer not to use it. These women may still seek help for their symptoms. So, what can we offer them?

There are pharmacological and non-pharmacological alternatives for which there is an imperfect but evolving evidence base, summarised by the BMJ (BMJ 2017;359:j5101). There are also some new drugs on the horizon.

Click below to read more about alternative treatments for menopause symptoms.

For much more information about the menopause and an opportunity to have all your questions about HRT answered, click to join our Women's Health team for our next Deep Dives webinar, The Menopause Laid Bare, streaming LIVE 25 June @8pm.

June is Motor Neurone Disease (MND) Awareness Month, and 21 June is Global MND Awareness Day

19 Jun 2019

We probably all associate the words 'motor neurone disease' with Stephen Hawking. His life with MND was just as extraordinary as his intellect. His diagnosis at a young age, long survival and the lack of progression over many years were all unusual. NICE produced new guidelines on motor neurone disease in 2016.

MND is rare. It can present at any age, though incidence is highest in 55-79 year-olds. Look for progressive, as asymmetrical features- most commonly limb or bulbar features:

Emergency contraception. Three options, but which will be most the appropriate and effective for your patient?

12 Jun 2019

There is a lot to consider in an emergency contraception consultation, including: assessing pregnancy risk; medical/drug history; ongoing contraceptive needs (possible quick starting); use of barrier methods/abstinence until protected; assessing STI risk and arranging testing; discussing the need to perform a pregnancy test 3w after unprotected sexual intercourse (UPSI) if an entirely normal period does not occur.....and, there is the question of which option is most appropriate.

In 2017, the FSRH updated its emergency contraception guideline. It notes that:

Osteomyelitis in children: how to spot it?

06 Jun 2019

Osteomyelitis is rare, presents insidiously, and is another of those conditions that is easy to miss! It is becoming more common in an era of increasing MRSA infection, and 50% of cases have no specific risk factors.

The classic picture of an unwell, febrile child with high white cell count is increasingly uncommon. There is no single or group of symptoms and signs that can be used to rule this in or out. Consider it in a child presenting with:

Back pain – mechanical or inflammatory?

30 May 2019

Jimmy, aged 38, tells you he is fed up with his ongoing back pain. It started some years ago, regularly disturbs his sleep but seems to improve once he gets up and gets moving. It responds well to ibuprofen which he has been purchasing over the counter. He has tried stretching and regular swimming, but it is getting worse rather than better. He has come hoping for a referral for physiotherapy.

But is his back pain mechanical or inflammatory?

Elevated prolactin. Might it be prolactinoma?

22 May 2019

On your list of telephone consultations is a message from the reception team about calling Aaliyah. She is "very worried and cannot wait till her usual doctor returns to discuss her raised prolactin blood test result," says the reception note.

Aaliyah, age 22, saw your colleague, concerned about infrequent period. Her friend was recently diagnosed with PCOS and she was anxious that she might have this too. She had no other clinical features of PCOS. Your colleague agreed to refer for a pelvic ultrasound scan and to check blood tests, including prolactin. The scan is awaited but the blood test results are back. They are normal apart from the prolactin which is elevated at 860mU/l.

Chronic pain and opiates

15 May 2019

In recent days, the media has focused again on the issue of opiate use and misuse with coverage of the trial of John Kapoor, "the first pharmaceutical boss to be convicted in a case linked to the US opioid crisis". Early last year, we sent out a Pearl on the chronic pain and opioid issue. The headlines this time around have been less sensational, simply asking the question, "Does the UK have an opioid problem?".

Highlighting that in the United States, President Donald Trump has declared a national health emergency because 130 people die every day from opioid-related drug overdoses, the BBC asks, "But are we really on the precipice of our own epidemic?".

Stroke and TIA

09 May 2019

The paramedics inform you “The FAST test is negative”. Do you wonder what they are talking about?

Do you use the ABCD2 score in TIAs?

If you answer yes to either of the above – read on – there are some big changes in practice to be aware of!

Statins and targets

01 May 2019

Statins "don't work well for one in two people" was the headline on the BBC. The article went on to say, "the scientists behind the findings are not sure why this is the case and don't recommend that anyone should stop taking statins before seeing their GP".

Patients who have heard or read this article may well come to us with questions. They might even have concluded that the statin they suspect causes them to ache does not work, and already stopped taking it.

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.