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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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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 we 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.

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.