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Tight foreskins – what can we do short of circumcision?

18 Feb 2020

Phimosis may be simply physiological and cause no problems. It may be secondary to an underlying skin disease. So, what do we need to look for, and what are the treatment options?

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Tight foreskins – what can we do short of circumcision?

Phimosis may be simply physiological and cause no problems. It may be secondary to an underlying skin disease. So, what do we need to look for, and what are the treatment options?

Phimosis may be physiological. It may be primary. It may be secondary to an underlying skin disorder. Whichever of these, and whether child or adult, your patient is likely to feel embarrassed about discussing the problem and awkward about physical examination.

If asymptomatic, it requires no treatment. But if it does require treatment, what should we offer? When might topical corticosteroids be appropriate and when should we refer?

Click on the PDF to see our summary of a BMJ review on phimosis and the British Association of Paediatric Urologists' statement on circumcision.

There are many other health issues that men might feel embarrassed or awkward about discussing with us! We too might feel uncertain about these issues.


Click to join us for our Deep Dive webinar: Men's Health Laid Bare.

We'll be coming to you live on Thursday 27 February 2020 at 8pm. Do you feel muddled by men's health? Perplexed by prostatitis? Bamboozled by testosterone bloods? We will tackle the issues of erectile dysfunction, the male menopause and much more!

We will cover:

  • Erectile dysfunction, including important initial investigations.
  • The role of PSA testing in these men.
  • Treatment and drug interations.
  • Testosterone deficiency - diagnosis, investigation and monitoring.
  • Quinolone prescribing following the NICE guidance on acute prostatitis released in 2018.

The format:

There will be an opportunity to take part in interactive polls, download some fantastic resources to support your practice, and ask our team your burning questions.

Join us live on Thursday 27 February 2020 at 8pm and then on demand from the next day.

An adrenal incidentaloma is noted on the scan report - what do you do next?

13 Feb 2020

The CTKUB scan showed a single small renal stone. However, that wasn't the only thing on the scan result: it reports a small lesion in the right adrenal gland, but unfortunately doesn't give you any advice on what to do next! So, what do you do?

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An adrenal incidentaloma is noted on the scan report - what do you do next?

The CTKUB scan showed a single small renal stone. However, that wasn't the only thing on the scan result: it reports a small lesion in the right adrenal gland, but unfortunately doesn't give you any advice on what to do next! So, what do you do?

You request a CTKUB. By the time you get the result, the patient has already rung to tell you that have "passed the little blighter", and indeed the scan showed a single small stone that was likely to come out on its own. However, that wasn't the only thing on the scan result: it reports a small lesion in the right adrenal gland, but unfortunately doesn't give you any advice on what to do next! So what do you do?

  • All adrenal incidentlomas need referring to endocrinology but take a history first: features such as hypertension, flushes or Cushingoid appearance that are pertinent to the referral may affect how quickly the patient is seen.
  • Most (85%) are benign and produce no hormones.
  • Lesions<4cm that are lipid-rich and produce no hormones are often left alone and need no ongoing monitoring, but that is a decision for the endocrinologists: our job is to refer!

Click on PDF to see our summary of 2018 BMJ Clinical Update on adrenal incidentalomas.

There are several options for the treatment of actinic keratosis, but which is the best?

05 Feb 2020

The options for treatment of actinic keratosis include topical and physical treatments, depending on the grading and location of the lesions. In January 2020, the marketing authorisation for ingenol was suspended due to risk of skin malignancy. We are asked to stop prescribing ingenol and consider other treatment options, as appropriate. So, what is the best treatment?

More info PDF

There are several options for the treatment of actinic keratosis, but which is the best?

The options for treatment of actinic keratosis include topical and physical treatments, depending on the grading and location of the lesions. In January 2020, the marketing authorisation for ingenol was suspended due to risk of skin malignancy. We are asked to stop prescribing ingenol and consider other treatment options, as appropriate. So, what is the best treatment?

There are several options for the treatment of actinic keratosis, including topical and physical treatments, depending on the grading and location of the lesions. But what is the best treatment?

A 2019 NEJM article looked at the effectiveness of four treatments that are field-directed: 5% fluorouracil cream, 5% imiquimod cream, photodynamic therapy and 0.015% ingenol mebutate gel.

5% fluorouracil cream was shown to be the best – and is the cheapest!

Is fluorouracil the first-line agent in your area?

Note that in January 2020, the marketing authorisation for ingenol was suspended due to risk of skin malignancy. We are asked to stop prescribing ingenol and consider other treatment options, as appropriate. We are also asked to advise patients to be vigilant for any skin lesions developing within the treatment area, and to seek medical advice promptly should any occur.

Has your local formulary/prescribing guideline been updated to reflect this change?

Click on the PDF to see our summary of a DTB review, a 2019 NEJM article, and the MHRA advisory on actinic keratosis and its treatment.

How confident do you feel when it comes to treating gout?

30 Jan 2020

When we are now encouraged to start disease-modifying treatment following a first attack of gout, how can we be confident enough in our diagnosis to recommend urate-lowering treatment? 

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How confident do you feel when it comes to treating gout?

When we are now encouraged to start disease-modifying treatment following a first attack of gout, how can we be confident enough in our diagnosis to recommend urate-lowering treatment? 

You might be confident based on your clinical judgement to start a course of treatment for an attack of gout, but are you confident enough to be recommending disease-modifying treatment with a first attack? When might diagnostic tests be indicated, and, importantly, does primary care scoring system that does not require aspiration perform better than clinical judgement alone?
 

Pete, age 58y, limps into your consulting room. “My big toe is killing me”, he says. “The same thing happened about a year ago but it went away with taking ibuprofen for a few days. Now I think this might be gout.”

Pete has hypertension which is controlled with ramipril. His right first MTP joint is red, swollen, warm and painful to move.

You feel confident, based on clinical assessment, to manage this episode as an attack of gout, but recall reading that we should start urate-lowering treatment after a first attack of gout. Are you confident enough to recommend disease-modifying treatment for Pete?

And what if you were less certain about the diagnosis, for example if it were his ankle affected rather than MTP joint? When do you need to consider diagnostic tests? Should you be considering joint aspiration?

For a typical attack, clinical features have a high likelihood ratio of being correct. However, a scoring system can improve accuracy of diagnosis. Pete will want to know that you are confident about your diagnosis if you are suggesting that he needs disease-modifying treatment. There is a primary care scoring system that does not require aspiration and that performs better than clinical judgement alone.

Click below to see our summary of the 2017 British Society of Rheumatology guideline on gout (which is endorsed by NICE) along with numerous other recent articles looking at diagnosis, investigation and management.

Are prophylactic antibiotics effective for recurrent UTI in the elderly?

23 Jan 2020

A study looking at patients over the age of 65y with a history of recurrent UTI found that use of prophylactic antibiotics reduced the risk of recurrent UTI by 51% in women and 43% in men. But there is more to this story!

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Are prophylactic antibiotics effective for recurrent UTI in the elderly?

A study looking at patients over the age of 65y with a history of recurrent UTI found that use of prophylactic antibiotics reduced the risk of recurrent UTI by 51% in women and 43% in men. But there is more to this story!

 

A study looking at patients over the age of 65y with a history of recurrent UTI found that use of prophylactic antibiotics reduced the risk of recurrent UTI by 51% in women and 43% in men. This had a corresponding effect of a 22% reduction in UTI-related hospital admission in men, but this was not seen in women. 

Of those who did get antibiotics, more than 50% took them for over 2 years!

This study did not look at antibiotic-related adverse events or at rates of resistant bacteria in urine, and the data is reliant on accurate read-coding of UTI diagnoses in primary care, so we cannot comment on the possible harms of prophylactic antibiotics for recurrent UTI in the elderly from these results.

So, food for thought when you next discuss recurrent UTIs with an older person, or do theo=ir medication review and see they have been on the antibiotic for 2 years!

Click below to see our summary of 2018 NICE guideance and articles from the BMJ and Age and Aging on recurrent UTIs.

Understanding the different roles in the ARRS

15 Jan 2020

Like it or loathe it, the PCN seems here to stay, though whether primary care stays with DES is a different matter altogether!

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Understanding the different roles in the ARRS

Like it or loathe it, the PCN seems here to stay, though whether primary care stays with DES is a different matter altogether!

One of the opportunities of the DES is the potential to integrate new roles into primary care to help solve some of the key challenges that many of us are facing, particularly shortage of GPs and increasing patient demand. This is also known as the Additional Role Reimbursement Scheme or ARRS.

Regardless of the outcome of the DES specification consultation and our individual practice choices about whether to participate, multidisciplinary primary care may be a good pragmatic option for many of our teams.

But this represents a big change and, like all change, if managed badly, it will cause more stress, disillusionment and wasted time. So, we need some pointers to make it work.

We are offering some resources and support to make this as easy as possible for you. You will find here one of a series of articles designed to help you navigate the complexities of this process of employing and utilising new professional groups within your team.

Done well, it may actually be the best thing to happen to primary care in years. So, what is the ARRS and how might it help us?

What should we advise for children with diarrhoea and vomiting?

08 Jan 2020

NICE advises us to offer oral rehydration solution to those 'at increased risk' of dehydration. But is oral hydration solution better than fruit juice for children with diarrhoea and vomiting?

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What should we advise for children with diarrhoea and vomiting?

NICE advises us to offer oral rehydration solution to those 'at increased risk' of dehydration. But is oral hydration solution better than fruit juice for children with diarrhoea and vomiting?


"I've tried to get Jimmy to drink the oral rehydration solution, but he spits it out. I tasted it and I don't blame it - it tastes awful!"

NICE advises us to offer oral rehydration solution to those 'at increased risk' of dehydration.

A Canadian study looked at whether oral rehydration solution is better than fruit juice for children with diarrhoea and vomiting. The group treated with dilute aplle juice was less likely to end up needing IV fluids than the group treated with oral rehydration solution!

However, 68% of the children in the trial showed no signs of dehydration, and the rest of the group showed only mild dehydration.

So, what can we tell from this?

  • We can stop using oral rehydration solution 'just in case' in non-dehydrated children with gastroenteritis.
  • There had previously been concerns that the high sugar content in fruit juice might increase diarrhoea, but this was not shown in this study.
  • For children with any clinical signs of moderate dehydration, oral rehydration solution may still be the most appropriate option PROVIDING the child will drink it!

Click below to see our summary of NICE guidance and articles from the Paediatrics, JAMA and NEJM on diarrhoea and vomiting in children.

What should you consider when your patient says, “I’m still coughing”?

02 Jan 2020

You've done a chest X-ray, treated them for reflux, given them a nasal spray to treat any post-nasal dip, and they are still coughing. What next?

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What should you consider when your patient says, “I’m still coughing”?

You've done a chest X-ray, treated them for reflux, given them a nasal spray to treat any post-nasal dip, and they are still coughing. What next?

  • First, get the patient to demonstrate their 'cough' as it might not be a cough after all!
  • Asthma, reflux and ACE inhibitors are the most common culprits.
  • Pay careful attention to red flags (in particular dyspnoea, haemoptysis, hoarseness, weight loss, fever, dysphagia and chest pain).
  • And don't forget to consider non-respiratory as well as respiratory causes.

The list of causes to consider is long but you don't have to remember it - just 'Red Whale it' when you need the info by looking for Cough: chronic article. 

Click below to see our summary of a 2019 DTB review and articles from the Lancet and BMJ on chronic cough.

What’s new with sinusitis?

11 Dec 2019

Winter’s back and so are patients presenting with sinusitis. So how can we change our practice on this? Read our article here: And join us for our webinar - Top 10 practice-changing points of 2019 – to hear about this and much more! Register here

More info PDF

What’s new with sinusitis?

Winter’s back and so are patients presenting with sinusitis. So how can we change our practice on this? Read our article here: And join us for our webinar - Top 10 practice-changing points of 2019 – to hear about this and much more! Register here

 

Sinusitis is part of the ‘bread and butter’ of primary care. Is there anything new? Anything that will radically change your practice? Yes, there is!

The 2017 NICE guidelines suggest:

  • Sinusitis is a self-limiting illness in most and usually lasts about 2–3w. Nothing new here!
  • Antibiotics make very little difference to duration of symptoms, probably because less than 2% of cases are complicated by bacterial infection. Again, nothing new here.
  • If you have to use antibiotics, and this will be a big change in practice, use phenoxymethylpenicillin for 5d because it is narrower spectrum than amoxicillin.
     

This change is one of our top 10 tips for 2019.

Click on the PDF button to see our summary of NICE guidance on sinusitis.

How do you handle a possible upper GI bleed?

04 Dec 2019

Your patient admits drinking too much and presents with epigastric pain. He also tells you he recently took ibuprofen for a painful shoulder. Could it be an acute upper GI bleed? What do you do next?

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How do you handle a possible upper GI bleed?

Your patient admits drinking too much and presents with epigastric pain. He also tells you he recently took ibuprofen for a painful shoulder. Could it be an acute upper GI bleed? What do you do next?

"I never look at my poo, I just flush it away", says Tony in response to your question trying to ascertain whether he has melaena. Tony is a 46-year-old who admits drinking more than he should and presents with epigastric pain. He took some ibuprofen last week for a painful shoulder. So, has Tony had an acute GI bleed?

Acute upper GI bleeding is common and serious, with 10% mortality. Peptic ulcer is the most common cause, followed by gastritis/duodenitis.

In the acute phase, a normal haemoglobin and normal blood pressure do not rule out a substantial bleed so we should not be reassured if these are normal. A raised pulse rate is more sensitive.

The bottom line is, we should refer all patients with a good history.

So, what are you going to do with Tony?

And what about management after an acute upper GI bleed? Can your patient ever again use NSAIDS? And what if they were on antiplatelets or anticoagulation?

Click on the PDF for our summary of a 2018 BMJ review regarding acute upper GI bleeds. We hope this summary will help you think through any such clinical dilemmas.

 

What are the alternative to opiates and gabapentinoids for our patients?

25 Nov 2019

Our understanding of the neurobiology of pain has completely revolutionised over the last few years. And because of that, lots of alternative management strategies for persistent pain have also emerged.

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What are the alternative to opiates and gabapentinoids for our patients?

Our understanding of the neurobiology of pain has completely revolutionised over the last few years. And because of that, lots of alternative management strategies for persistent pain have also emerged.

Read more below about managing chronic pain and for even more resources, watch our FREE chronic pain webinar!

A cry we are hearing a lot on our GP Update and MSK courses at the moment is, "We can't use opiates, we can't use gabapentinoids, what can we use for patients with chronic pain?".

Unfortunately, there is not a quick-fix, easy answer: no single tablet that will cure chronic pain. But there is a lot we can do. Our understanding of the neurobiology of chronic pain has changed beyond recognition since many of us were at medical school. In our next VA webinar, we will unpack this and start to talk about consultation strategies, specific self-mangement skills and great resources.

The International Association for the Study of Pain (ASP) defines pain as: an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

This definition contains several important elements:

  • Pain is an experience, i.e it is subjective.
  • Pain is both a sensation and has an emotional aspect.
  • Tissue damage is not necessary for pain to exist.
  • The patient's description of their pain may be the same whether or not the tissue damage is present.

Nocicption is the neural process of encoding noxious stimuli. It is triggered when noxious stimuli act on specialised peripheral nerve endings.

However:

  • It does not necessarily result in the individual perceiving pain.
  • It is also possible for an individual to perceive pain when there is nociception. This occurs in some chronic pain states.

Most clinicians and lay people continue to view pain according to the biomedical model. We in primary care treat teh physical, psychological and social problems of our patients on a daily basis, and use the biopsychosocial model routinely for medical problems such as depression or anxiety. A biopsychosocial approach to patients with chronic pain is essential in understanding and treating their pain effectively.

Click on the PDF to see our introductory article, 'The biopsychosocial model of pain'

When should patients take blood pressure pills?

19 Nov 2019

A huge study on hypertension found that bedtime is best, with the bedtime dosing group having almost half as many CV events as the morning dosing group! What does this mean for your practice?

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When should patients take blood pressure pills?

A huge study on hypertension found that bedtime is best, with the bedtime dosing group having almost half as many CV events as the morning dosing group! What does this mean for your practice?

 

"Jaw-dropping" is how Dr Mark Porter, writing in The Times, described recently-published research looking at when is the best time of the day to take blood pressure medication.

And the conclusion of the study: bedtime!

The bedtime dosing group had almost half as many cardiovascular events as the morning dosing group.

Many of your hypertensive patients may be aware of this research from the media attention it has been given. They may be wondering what it means for them.

We have summarised the findings of the study published in the European Heart Journal looking at why this might be, and what it means in practice.

Click on the PDF to see our summary of the 2019 European Heart Journal article.

How does varicoceles affect male infertility?

13 Nov 2019

Varicoceles happen in 15% of adolescent boys & men. Two thirds have no fertility problems, but for others it's linked to reduced sperm quality. What do you when a patient is experiencing infertility or worried about it?

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How does varicoceles affect male infertility?

Varicoceles happen in 15% of adolescent boys & men. Two thirds have no fertility problems, but for others it's linked to reduced sperm quality. What do you when a patient is experiencing infertility or worried about it?

You have reassured Charlie that the swelling he felt in his scrotum is just a varicocele and is not cancer. However, he still looks anxious and asks, "will this mean I cannot have a child?".

Varicoceles are common, occurring in 15% of adolescent boys and men. Two-thirds of men with a varicocele do not have problems with fertility, though varicoceles do increase scrotal temperature, reduce testicular perfusion, and are associated with reduced sperm quality in observational studies.

Embolisation of large varicoceles may improve sperm quality. However, NICE concludes that varicocele surgery should not be offered as fertility treatment because it does not improve pregnancy rates.

Infertility is the failure to conceive after >1y of reguar unprotected sex. One in seven couples in teh UK access infertility treatent. Abnominal semen analysis occurs in nearly half of couples with infertility.

Male infertility can be caused by hormonal, testicular or obstructive factors, or may be functional. No cause is identified in a third of cases. Where possible identification of the underlying cause can help guide advice, investigation and referral.

If semen analysis is abnormal, we should repeat the sample and advise regarding reversible causes of semen abnormalities, assess for the underlying cause of male infertility, arrange bloods and if clinically appropriate an ultrasoud scan. We can then refer to fertility services along with referral to endocrinology/urology, as required.


Click on the PDF to see our summary of a 2018 BMJ article and the 2018 NICE CKS on male infertility.

How do you know when an acute asthma exacerbation is severe or life-threatening?

05 Nov 2019

What are the protocols and what should we do about management? Check out this handy summary of protocols we created, which you might even want to stick on your treatment room wall!

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How do you know when an acute asthma exacerbation is severe or life-threatening?

What are the protocols and what should we do about management? Check out this handy summary of protocols we created, which you might even want to stick on your treatment room wall!

We should treat every attendance with an asthma exacerbation as severe asthma until proven otherwise.

So, what suggests that an acute asthma exacerbation is severe or life threatening?

PEFR is an important indicator, and we need to be able to measure oxygen saturation, but we should not rely on a single sign. We must look at the whole picture.

And then, for management:

How should we give sabutamol? Should we give oxygen? Should we give prednisolone? Should we give antibiotics?

And then, for management:

How should we give salbutamol? Should we give oxygen? Should we give prednisolone? Should we give antibiotics? When should we admit?

Click on the PDF to see our acute asthma protocol for adults and for children based on SIGN/BTS guidelines. You might wish to print these two A4 pages for your emergency bag or treatment room wall, or use them as the basis of your own practice protocol.

We should treat every attendance with an asthma exacerbation as severe asthma until proven otherwise. And, if you would benefit from brushing up on primary care emergencies in adults, we cover much more in our webinar on Emergencies in Primary Care. Click here to register and watch on demand.

Emergencies are relatively rare in primary care so, when they do occur, we need to feel skilled and confident to manage them. Join our Red Whale team and Dr Graham Johnson, Emergency Medical Consultant, to brush up on primary care emergencies in adults.

We cover:

  • Common things that can be tricky, e.g. head injuries, venous thromboembolism.
  • Rare things we don't want to miss.
  • Top tips for pre-hospital care that can make a difference while waiting for that ambulance.
     

The format:

There will be an opportunity to consider some real cases, take part in interactive polls and quizzes, download some fantastic resources to support your practice, and ask your burning questions to Graham and our team
.

Watch our webinar on demand:  Emergencies in Primary Care.

How do we manage lung cancer in primary care?

31 Oct 2019

UK lung cancer survival rates lag a long way behind some of Europe and we need to make earlier diagnoses. How can we change our practice?

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How do we manage lung cancer in primary care?

UK lung cancer survival rates lag a long way behind some of Europe and we need to make earlier diagnoses. How can we change our practice?

We've teamed up with Macmillan to bring you this Pearl and free webinar on Lung Cancer.

We can make earlier diagnosis in primary care by:

Remember, beware the negative CXR - if we still have a degree of suspicion, we should refer!

So, when should we order a chest radiograph?

Lung cancer does not always present with a clear symptom signature, and affected individuals often have comorbidities that could confuse the picture. While haemoptysis is the most predictive isolated symptom, it only occurs in 20% of those with a final diagnosis of lung cancer. Remember more unusual presentations such as thrombocytosis, appetite loss, shoulder pain and worsening spirometry, especially in smokers. NICE offers clear guidance on how we should approach patients presenting with symptoms that could be suggestive of lung cancer.

And remember too that stopping smoking is beneficial at any stage, even after a diagnosis of lung cancer.

Click on the PDF button to see our summary of NICE guidance and recent BMJ and BJGP articles on the diagnosis of lung cancer.

Yes, our headline about UK survival rates from lung cancer sounds depressing. But there is hope in the form of screening for earlier detection and evolving innovative immunotherapy-based treatments. Our key challenges in primary care are prevention through smoking cessation, helping patients spot it early and supporting patients through ever-more-complex regimens.

If you are interested in learning more about this, click to watch our webinar "
Lung cancer in Primary Care" on demand produced in association with Macmillan Cancer Support.

 


 

Subclinical hypothyroidism – overdiagnosis or worth treating?

23 Oct 2019

It’s a dilemma in patients with a raised TSH and normal T4: a small % develop overt hypothyroidism, but many will see their TSH levels normalise over 2 years. What should we do?

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Subclinical hypothyroidism – overdiagnosis or worth treating?

It’s a dilemma in patients with a raised TSH and normal T4: a small % develop overt hypothyroidism, but many will see their TSH levels normalise over 2 years. What should we do?

We have several dilemmas when we encounter a raised TSH with normal T4. Each year, a small percentage of these patients will develop overt hypothyroidism. But with a single raised TSH of less than 7mIU/L, there is a 50% chance of the level normalising over 2 years.

 

What about CHD risk? A meta-analysis has shown that, overall, there was no difference in CHD incidence, CHD mortality or overall mortality between those with subclinical hypothyroidism and those who were euthyroid. However, those who had a TSH ≥10mU/L at presentation had a significantly increased risk of CHD and CHD mortality, but no difference in overall mortality.

There is evidence that treating subclinical hypothyroidism does not improve symptoms or quality of life.

There is insufficient data to look at whether treatment reduces the risk of CVD.

So, is this overdiagnosis? Shared decision-making and monitoring rather than treating is a very reasonable option until the evidence catches up and definitively guides us as to whether there are long-term benefits of treatment.

Please note: this does not apply to pregnant women for whom treatment of subclinical hypothyroidism is still recommended.


Click below to see our summary of a 2017 NEJM review, a 2018 meta-analysis in JAMA and other articles on subclinical hypothyroidism.

What’s the evidence on linking hormonal contraception to depression?

14 Oct 2019

Some research links hormonal contraception with increased antidepressant use, and even suicide. But does the evidence support this?

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What’s the evidence on linking hormonal contraception to depression?

Some research links hormonal contraception with increased antidepressant use, and even suicide. But does the evidence support this?

"Can I change to a different pill?", Abigail asks. "I have been having terrible mood swings. It all seems to be since I started the pill 3 months ago. This is just not like me. My partner and friends have noticed it and are worried. It must be the pill."

So, what is the evidence around hormonal contraception and depression? And how will you advise Abigail?

  • Research from Scandanavia has found that use of hormonal contraception may be associated with increased antidepressant use and an increased risk of suicide.
  • The FRSH points out that there are limitations to studies in this area, and they do not prove a casual link between hormonal contraceptive use and depression.
  • Mood disorders in women may be mutifactorial.
  • A history of depression is NOT a contraindication (UKMEC 1) to any method of contraception.
  • Offering women contraceptive choice reduces the risk of an unintended pregnancy which could worsen her mental health.
  • We should counsel women about possible side-effects of hormonal contraception - including mood changes - and offer an alternative if a specific method is causing problems.
     

For more on the studies that have looked at this, the evidence, and how this should affect our practice:

Click the PDF button to see our summary of a number of recent articles and FSRH CEU statements on hormonal contraception and depression

What’s all the fuss about FIT?

09 Oct 2019

Several indications for use, different cut-off thresholds for different uses...We summarise the NICE guidance, BJGP and other articles on the use of the faecal immunochemical test.

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What’s all the fuss about FIT?

Several indications for use, different cut-off thresholds for different uses...We summarise the NICE guidance, BJGP and other articles on the use of the faecal immunochemical test.

The faecal immunochemical test (FIT) is a new way to test for occult blood in stool. It is replacing the traditional guaiac-based faecal occult stool test.

FIT can detect human haemoglobin in stool at very low levels. It has a much lower false positive rate than guaiac testing because it is not influenced by food consumed. It is specific for lower GI blood loss and requires one test, rather than three – so, if your patient is sent just one test kit, the FIT is being used. It is a quantitative test so the amount of blood in the stool can also be determined. This allows different thresholds to be set which will adjust the sensitivity and specificity of the test.

There are three ways the FIT test can be used, each of which involves different cut-off thresholds being applied.

  • Colorectal cancer screening: FIT is the screening test of choice for the national screening programme from 2019.
  • Patients with ‘low-but-not-no-risk’ symptoms for colorectal cancer: used as a ‘rule-in’ test. Those testing positive are most likely to benefit from an urgent colonoscopy. A negative FIT makes a diagnosis of colorectal cancer unlikely BUT, if symptoms persist, further investigations (for colorectal or other cancers) should be considered: safety-net well.
  • To triage 2ww colonoscopy list: as a rule-out test for patients with higher risk symptoms who meet referral criteria. This is controversial and is not part of standard practice yet. It is being tested in large clinical trials to see if it is safe to use in this context.
     

NICE updated its ‘Suspected cancer referral guidelines’ to recommend the FIT rather than the guaiac FOB test. NICE says we can offer faecal immunochemical testing to assess for colorectal cancer in people without rectal bleeding who have unexplained symptoms that could be suggestive of colorectal cancer but who meet no other referral criteria, allowing us the freedom to decide when the test might be appropriate and to refer if positive.

Click the PDF button to see our summary of the NICE guidance, BJGP and other articles on the use of the faecal immunochemical test.

Do emollients really pose a fire risk?

02 Oct 2019

Emollients are the mainstay of treatment for eczema. But people do die from emollient-associated fires and it’s that time of year when people switch their heating on. What should we advise patients?

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Do emollients really pose a fire risk?

Emollients are the mainstay of treatment for eczema. But people do die from emollient-associated fires and it’s that time of year when people switch their heating on. What should we advise patients?

People can, and do, die from fire associated with emollient use.

In 2018, the MHRA recommended that patients should be given 'clear advice not to smoke or go near naked flames, and information about the risk of severe burn injury or death when clothing, bedding and dressings with emollients dried on them are accidentally ignited'.

This advice applies to all emollients, whether they contain paraffin or not.

Emollients are the mainstay of treatment for everyone with eczema. They should continue to be used when stepping up treatment.

Autumn is here and patients will be starting to turn on their heating - so now may be the time to think about fire risk and advise patients.

Click the PDF button to see our summary of the 2018 MHRA guidance on fire risk as well as SIGN and NICE guidance on eczema.

Osteoarthritis: which treatments work and how do we encourage self management?

26 Sep 2019

Osteoarthritis is extremely common and a growing problem in the UK. We spend between 1 and 2.5% of our GDP on the direct costs of this condition and the indirect costs are likely to be even higher.

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Osteoarthritis: which treatments work and how do we encourage self management?

Osteoarthritis is extremely common and a growing problem in the UK. We spend between 1 and 2.5% of our GDP on the direct costs of this condition and the indirect costs are likely to be even higher.

And yet, many patients with osteoarthritis report feeling unsupported and feel they have to ‘accept’ their arthritis as an inevitable part of ageing.

Primary care can make a big difference to patients with osteoarthritis, but what can we say, and how we say it, really matters. The old adage of 'wear and tear' just doesn't fit the bill. If we think about it, phrases like this imply an inevitable need for surgery and don't make it particularly likely that our patients will engage in exercise and movement...I mean, if your brakes are 'worn and torn', you don't want to take the car out for a long drive.

So, what can we do instead? How can we share understanding of the condition and help patients to engage in self-management? What core treatments do work and where can we access them?

We have teamed up with Versus Arthritis to bring you a Pearl on osteoarthritis – it’s a long one but worth digesting with a nice cup of tea. And we've produced a free webinar: Osteoarthritis: primary care matters, watch on demand today.

How do we tackle addiction to prescribed drugs?

19 Sep 2019

Shocking headlines appeared in the press recently: ‘1 in 4 people take addictive medicines’, prompting ‘The NHS must take action!’. Where have these numbers come from, are they true, and what can we do?

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How do we tackle addiction to prescribed drugs?

Shocking headlines appeared in the press recently: ‘1 in 4 people take addictive medicines’, prompting ‘The NHS must take action!’. Where have these numbers come from, are they true, and what can we do?

'1 in 4 people take addictive medicines', finds a Public Health England review. The Mail Online says, 'The NHS must take action!'

So, where have these numbers come from - and what can we do?

These reports were based on PHE prescribing analysis using CPRD data from 2017. The analysis looked at 5 drug classes: antidepressants, benzodiazepines, Z-drugs, opiods and gabapentinoids.

In 12 months between 2017 and 2018, 11.5 million adults in the UK were prescribed at least one of these drugs. To put this into context, this means around 17% of the adult population were being prescribed antidepressants and around 3% were being prescribed gabapentinoids. These prescription rates are higher in women, and higher in areas of deprivation.

The average duration of prescription has gone up from 3 months to over 12 months since the last evaluation in 2015. This report also attracted a fair bit of controversy about whether antidepressants should have been lumped indiscriminately in with these other drug classes, and this is a legitimate point.

 

In light of these findings, PHE made several recommendations to the NHS to promote awareness of the harms of these drugs and better shared understanding with patients:

1. Make prescribing data more transparent and accessible (Ben Goldacre's site
https://openprescribing.net/ is a good place to start if you want to find out about your own trends).

2. Improve patient information leaflets on these treatments.

3. Improve NHS support for patients with dependence on these drugs.

4. Do further research on prevention and treatment of dependence on prescribed drugs.

5. Set up a national drug dependence patient helpline.

While these aims are laudable, they don't give us, as clinicians on the ground, many useful tools we can use with our patients who are struggling with chronic pain.

At Red Whale, we recognise that managing chronic pain in primary care with limited resources is an area many of us fid challenging. Introducing the concept of self-care to patients can be difficult for us and patients. Our medical model is that we should be able to 'do something' for the patient, and the patient can perceive that the idea of self-care is suggesting they are 'wasting our time' or it is 'all in their heads'.

This is a complex area, so much so that we dedicate a whole course to it. But we would liek to share with you some of the strategies we have found helpful around introducing the concept of self-care. This is one part of the jigsaw
.

Click on the PDF button if you'd like to read more. This is a link to the article on the self-care and self-management from our MSK course.

How do we successfully negotiate in primary care?

12 Sep 2019

Negotiating a deal. Blocking a deal. No deal. That's been the seemingly endless story of Brexit. But negotiation and deal-making is important in primary care too and many of us find it a challenge. How do we negotiate successfully?

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How do we successfully negotiate in primary care?

Negotiating a deal. Blocking a deal. No deal. That's been the seemingly endless story of Brexit. But negotiation and deal-making is important in primary care too and many of us find it a challenge. How do we negotiate successfully?

Do we do any better? Are we any better equipped? What skills do we have in negotiation in the everyday world of primary care?

Many of us find the concept of negotiation a little challenging and anxiety-inducing.

We might rarely have to negotiate finances, job conditions or contracts, but that's not to say we don't ever negotiate. We are entering the new world of Primary Care Networks - this is likely to involve negotiation. And what about the times we have to persuade someone to do a scan or admit a patient? Or when we identify something we would like to change in our own practices? Or when swapping a late evening or weekend surgery?

What is a successful negotation?

A win/win approach
This is the basis of a successful negotiation. You can tell you have achieved this if:

  • Both parties are happy with the outcome.
  • Both parties have gained something from the outcome.

This is the best possible outcome for negotiation but might not always be possible.

 

A no win/no deal approach
If a win/win situation cannot be found, I might decide that, in order to avoid recriminations down the line, a 'no deal' outcome is better than a win/lose or lose/win situation.

In many ways, a no win/no deal approach is best if a win/win can't be found.

This is because of the ongoing damage to working relationships that can be caused when one person wins and one loses.

In negotiation:

  • Always go for a win/win outcome.
  • There is often more than one pie - look for the 'third alternative'.
  • Separate people from the problem.
  • Base negotiations on interests, not positions.
  • Use objective criteria and facts.
  • Be creative in generating options.

Good negotiating skills can be a real bonus in many areas, including work, home and family life.

We explore some concepts and ideas which may help the world of negotiation become a lot less scary.

Click on the PDF button to see the section on a win/win approach from our article 'Negotiation: improving my negotiating skills'.

How do we get our diabetes patients into remission?

02 Sep 2019

We know we can control diabetes using drugs. But, if we can support our patients to change their lifestyle and lose weight, there’s a good chance we can put their diabetes into remission. Evidence is building that low-carb diets benefit diabetes patients.

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How do we get our diabetes patients into remission?

We know we can control diabetes using drugs. But, if we can support our patients to change their lifestyle and lose weight, there’s a good chance we can put their diabetes into remission. Evidence is building that low-carb diets benefit diabetes patients.

There is increasing evidence for the benefit of low-carb diets in diabetes. But these involve significant lifestyle changes and hard work on the part of our patients in order to achieve the benefits.

The conversations we are having with our diabetic patients are changing. So, the big question for us is, how do we enable our patients to make the changes required?

Click on the PDF button to see our summary of trials looking at low-carb diets in diabetes published in the Lancet and the BMJ in 2018.

If you are interested in learning more about this and want to take the next steps in building your skills at empowering your patients to embrace lifestyle change, register to watch our  "Diabetes in remission: A story of hope" webinar on demand.

 

 

Which self-help books can I recommend for mental health issues?

29 Aug 2019

You may hear “I don’t like talking with strangers”, or “That’s not for me” when suggesting IAPT services. But some patients may engage better with books, so we’ve compiled a list of the ones we recommend.
 

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Which self-help books can I recommend for mental health issues?

You may hear “I don’t like talking with strangers”, or “That’s not for me” when suggesting IAPT services. But some patients may engage better with books, so we’ve compiled a list of the ones we recommend.
 

If patients can engage with a book, there are some great resources that might be all they need, or might even break the ice on the idea of seeking appropriate talking therapy.

The Reading Agency with the Society of Chief Librarians has complied a list of books recommended for adults, and a list for young people. We hope that both you and your patients will find these resources helpful.

Click on the PDF button to see the lists of self-help books for adults and for young people.

 

Why is the UK seeing a rise in measles cases?

21 Aug 2019

Recent headlines really brought this to the fore. Population immunity of more than 95% is needed to prevent ongoing transmission. But just 87% of children in England get their 2nd dose of MMR and now the UK has lost its measles-free status.

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Why is the UK seeing a rise in measles cases?

Recent headlines really brought this to the fore. Population immunity of more than 95% is needed to prevent ongoing transmission. But just 87% of children in England get their 2nd dose of MMR and now the UK has lost its measles-free status.

 

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!

The WHO classes a country as having 'eliminated' the disease when it has stopped freely circulating for at least 3 years. This is not the same as eradication! Clusters of infection had still been occuring in the UK, but herd immunity had ensured that wider transmission had not followed. Population immunity of more than 95% is necessary to prevent ongoing transmission. Just 87% of children in England are receiving their second dose of MMR, although the rest of the UK is doing better. Vaccine uptak eof first dose falls below 80% in London. There is a very real risk of wider transmission. Outbreaks and transmission tend to occur in unvaccinated or incompletely-vaccinated individuals.

Many primary care clinicians will have never seen a case of measles!

Importantly, two-thirds of recent confirmed cases are in individuals aged 15y or older.


Two doses of the MMR vaccine are thought to offer lifelong protection. It is therefore essential to continue our efforts to achieve high rates of immunisation uptake through the routine immunisation schedule, and offer opportunistic vaccination to individuals >1y with an incomplete history.

  • In a flu-like illness with conjunctivitis that is followed by a rash, think about measles.
  • Remember, unvaccinated or incompletely-vaccinated individuals are at greatest risk.
  • Test for measles IgM and notify your local HPU - it may offer some individuals post-exposure prophylaxis.
  • Isolate at home until at least 4d after the rash appears and manage symptomatically.
     

Click on the PDF button to see our summary of a 2017 BMJ article on measles in older children and adults from the Easily Missed series.

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