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Ankle swelling and the diuretic dilemma

25 Feb 2021

Increased ankle swelling in those with known heart failure has many possible causes. This week's Pearl this week is our top ten take home messages from a useful BMJ article from 2020, and a reminder of the differential diagnoses of ankle swelling and decompensated heart failure.

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Ankle swelling and the diuretic dilemma

Increased ankle swelling in those with known heart failure has many possible causes. This week's Pearl this week is our top ten take home messages from a useful BMJ article from 2020, and a reminder of the differential diagnoses of ankle swelling and decompensated heart failure.

Mrs O’Dema is on your list again today, asking for review of her swollen legs which are worse than ever. A quick check of her records reminds you she has diagnoses of heart failure and CKD. She had an episode of cellulitis around 6 months ago, and her drugs list is as long as your arm. So, what are you going to do? Bump up her furosemide dose a notch and see how she is in 48 hours? The trouble is, it’s a little bit more complicated than that!

Increased ankle swelling in those with known heart failure has many possible causes. Even if we do think the problem here is decompensated heart failure, we still need to consider WHY that has happened. And once we have worked that out, we need to know how to make sure the diuretics we use are going to work! I don’t know about you, but my understanding of the pharmacology of loop diuretics is sketchy at best.

Your Pearl this week is our top ten take home messages from a useful BMJ article from 2020, and a reminder of the differential diagnoses of ankle swelling and decompensated heart failure.

A Primary Care Guide to Giant Cell Arteritis

18 Feb 2021

Giant cell arteritis is a medical emergency, and prompt identification can prevent sight loss. Click PDF to read this our Pearl in association with Versus Arthritis and hear more on this by watching our upcoming FREE webinar.

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A Primary Care Guide to Giant Cell Arteritis

Giant cell arteritis is a medical emergency, and prompt identification can prevent sight loss. Click PDF to read this our Pearl in association with Versus Arthritis and hear more on this by watching our upcoming FREE webinar.

For this week’s PEARL, we have teamed up with Versus Arthritis to share with you the new British Society of Rheumatology guidance about spotting and managing GCA, and how we can work together with our secondary care colleagues to deliver really good care. Key messages are:

  • The importance of having a high index of suspicion.
  • If we think it is GCA and this is THE most likely diagnosis, we should take bloods that same day, start steroids and pick up the phone to speak to a rheumatologist.
  • If there is visual disturbance, we should arrange IMMEDIATE ophthalmology assessment.
  • If we think GCA is one of a number of possibilities, we should still pick up the phone and speak to rheumatology to agree a plan for further investigation and whether to start steroids.
  • GCA patients are on high doses of steroids: they need regular shared care follow-up to monitor comorbidities, e.g. hypertension, diabetes, and for side-effects.
  • All will need a steroid treatment and a steroid emergency card.
  • Nearly all will need bone and gastro-protection.

How are you doing in your practice? To read more, click PDF to read our PEARL, and do share with your colleagues. 

Want to know more? Join Red Whale and Versus Arthritis for our FREE webinar, Giant Cell Arteritis and Polymyalgia Rheumatica: The Primary Care Guide, which will be available to watch from Tuesday 23 February. To sign up, click here.

Long COVID-19 symptoms: how can we recognise and start to manage them in primary care?

11 Feb 2021

How should we best respond to post-COVID syndrome in our patients? When do we transition from thinking about the acute harms of COVID-19, needing to check chest X-rays, D-dimers and heart markers, to thinking about long-term rehabilitation?

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Long COVID-19 symptoms: how can we recognise and start to manage them in primary care?

How should we best respond to post-COVID syndrome in our patients? When do we transition from thinking about the acute harms of COVID-19, needing to check chest X-rays, D-dimers and heart markers, to thinking about long-term rehabilitation?

As the illness developed, I felt so unwell I thought I was dying. The roller-coaster that followed lasted for months, with sudden waves of illness and malaise, like being hit by a cricket bat. I had a foggy head, acutely painful calf, upset stomach, tinnitus, aching all over, breathlessness, dizziness, arthritis in my hands, weird sensation in my skin, extreme emotions, and utter exhaustion and body aches throughout. I had ringing in my ears, intermittent changes to my heartbeat, and dramatic mood swings. After three months I was unable to be out of bed for more than three hours at a stretch. 

 

This is a quote from a BMJ blog by Professor Paul Garner on his experience of the symptoms of long COVID (BMJ 25/01/2021).

It can be difficult, given how little is known about the long-term consequences of this new disease, to know how best to respond to post-COVID syndrome in our patients. How worried do we, and they, need to be? When do we transition from thinking about the acute harms of COVID-19, needing to check chest X-rays, D-dimers and heart markers, to thinking about long-term rehabilitation?

NICE has released a ‘living guideline’ on the topic – openly acknowledging that as knowledge develops, our understanding will need to be updated. We have summarised the current evidence base and the NICE guidance in one of our GEMS (Guidelines and Evidence Made Simple); this should give you a starting point you can have at your fingertips during your next consultation on this topic.

Caring for Patients Living with HIV

04 Feb 2021

The development of effective antiretroviral treatment for HIV has led to it becoming a chronic disease rather than the death sentence it was in the 1980s (hurray!). Adherence to treatment can mean ‘near normal’ life expectancy.

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Caring for Patients Living with HIV

The development of effective antiretroviral treatment for HIV has led to it becoming a chronic disease rather than the death sentence it was in the 1980s (hurray!). Adherence to treatment can mean ‘near normal’ life expectancy.

With the advent of pre-exposure prophylaxis, we have a strategy to prevent transmission.

However, for those living with HIV, the disease itself and its drug treatment comes with increased risk of comorbidities and adverse events.

This week’s Pearl looks at a paper from the BJGP which guides us on considerations for clinicians in primary care when caring for this group of patients (BJGP 2019;69:407).

COVID & Vitamin D

28 Jan 2021

This week, we are looking at a controversial topic: vitamin D and COVID-19! Does vitamin D help prevent COVID-19? If so, who should take it and in what doses?

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COVID & Vitamin D

This week, we are looking at a controversial topic: vitamin D and COVID-19! Does vitamin D help prevent COVID-19? If so, who should take it and in what doses?

The Government has announced that every Clinically Extremely Vulnerable person in the UK can sign up to be sent vitamin D to take while they shield, if they apply before 21 February. But we are still taking calls from worried patients who want to know if we can prescribe it, and whether they/their elderly parent/dog should be taking daily vitamin D? So, what should we do? 

COVID-19: Updated Pearl

21 Jan 2021

COVID-19 knowledge has moved on considerably since we first created our Pearl about this new virus, almost a year ago. Read the latest version of our COVID-19 Pearl by clicking the button below.

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COVID-19: Updated Pearl

COVID-19 knowledge has moved on considerably since we first created our Pearl about this new virus, almost a year ago. Read the latest version of our COVID-19 Pearl by clicking the button below.

Early in 2020, here at Red Whale HQ we gathered everything we knew about the new virus COVID-19 into a Pearl to share with you. We hoped we could help everyone in primary care face up to new challenges with confidence in their knowledge base.

Almost a year later and COVID-19 is still at the forefront of all our working lives (and our non-working lives, too!). Some aspects of medicine during a pandemic have become almost ‘normal’ now, and although this might not be how we would choose to work, we have pulled together and performed the amazing feat of revolutionising primary care to respond to this disease.

COVID-19 knowledge has not stood still over the past year. We now know so much more than we did then, thanks to colleagues like Professor Greenhalgh and her team. So, we have updated our COVID-19 Pearl, looking at what we know and where the big clinical uncertainties remain.

Over the next few weeks, as we work through lockdown and home-schooling, not to mention organising an unprecedented vaccination programme for our most vulnerable patients, we will be sharing several more COVID-19 Pearls. We hope they help.

Motivating behaviour change: could this be your new year’s resolution?

07 Jan 2021

Interventions in primary care can make a real difference to patients making changes in their behaviour, but how can we help our patients (and ourselves) see that change IS possible?

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Motivating behaviour change: could this be your new year’s resolution?

Interventions in primary care can make a real difference to patients making changes in their behaviour, but how can we help our patients (and ourselves) see that change IS possible?

The turning of the year is traditionally a time to reflect and make plans for the year ahead. But new year’s resolutions can prove tricky to keep, and we are not always ready or able to make a behaviour change that involves a major commitment or effort.

We know that brief interventions in primary care can make a real difference to patients making changes in their behaviour, but it can feel like an uphill battle squeezing this into an already crowded consultation. So, how can we help our patients (and ourselves) see that change IS possible?

This week, our new year’s resolution Pearl is all about David Unwin’s GRIN model for motivating behaviour change. This provides a straightforward and useful approach to facilitate making changes, breaking the change down into manageable steps. Click PDF for full article.

eGFR vs. creatinine clearance, when is the first ok, and how should we calculate the second?

17 Dec 2020

When it comes to calculating the patient’s creatinine clearance, which formula should you use? We look at the difficulties of accurately estimating creatinine clearance in primary care, and some useful tips on the particular at-risk groups.

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eGFR vs. creatinine clearance, when is the first ok, and how should we calculate the second?

When it comes to calculating the patient’s creatinine clearance, which formula should you use? We look at the difficulties of accurately estimating creatinine clearance in primary care, and some useful tips on the particular at-risk groups.

It’s late at night on a busy December on-call day. You’ve managed an extended hours flu vaccination list; visited 3 nursing homes and somehow avoided prescribing antibiotics for ‘?UTI’ 5 times; amazed a snotty febrile child with your fantastic lion impression; and generally been an all-round primary care star. And now you’re looking at the U&E result for that new atrial fibrillation patient you saw earlier today. You sent them home with a DOAC to use (among other things). Their eGFR is 45.

The recommended dose in AF is 20mg once daily, but the dose should be reduced to 15mg once daily if creatinine clearance is 15–49mL/min.

So, should you prescribe 15 or 20mg?

You decide you had better calculate the patient’s creatinine clearance.

But which of the several formulas should you use? Our Pearl this week is all about the difficulties of accurately estimating creatinine clearance in primary care, with some useful tips on the particular at-risk groups to consider. Click PDF to read full article.

COVID-19 Vaccinations & Anaphylaxis GEMS

10 Dec 2020

This week, two NHS workers (with existing severe allergy and who carried epipens) had anaphylactoid reactions following vaccination. So, we thought we would share with you our new GEMS on anaphylaxis, which includes a protocol for management and the updated NICE 2020 guidelines.

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COVID-19 Vaccinations & Anaphylaxis GEMS

This week, two NHS workers (with existing severe allergy and who carried epipens) had anaphylactoid reactions following vaccination. So, we thought we would share with you our new GEMS on anaphylaxis, which includes a protocol for management and the updated NICE 2020 guidelines.

Many of us in primary care are anticipating our first delivery of the Pfizer/BioNTech COVID-19 vaccination on Monday, and there has been a rush to get those mandatory e-learning e-learning modules signed off!

Mainstream media reported yesterday that the MHRA has recommended that:

  • People with a history of immediate-onset anaphylactic reactions to medicines, food or vaccines should not have the Pfizer/BioNTech vaccine, and anyone who has an anaphylactic reaction to the first dose should not have a second dose.  

This is because on the first day of administration, two NHS workers (with existing severe allergy and who carried epipens) had anaphylactoid reactions following vaccination. They have completely recovered. This event is not unexpected – with most vaccines, we see the occasional anaphylactic/ anaphylactoid reaction – so it is important that we are prepared for this if we are administering vaccines.

The MHRA also states that a protocol for the management of anaphylaxis and an anaphylaxis pack must always be available when the Pfizer/BioNTech is given (as it should when any vaccine is given!).

So, we thought we would share with you our new GEMS on anaphylaxis, which includes a protocol for management and the updated NICE 2020 guidelines. Click PDF to read our GEMS. Print it out, stick it on your wall, share it round with our compliments.

All that itches is not thrush!

03 Dec 2020

Women can often be embarrassed to talk about problems they might be having ‘down there’. But vulval discomfort is common, affecting up to 7% of women, so this week we summarise how to identify and manage common vulval conditions.

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All that itches is not thrush!

Women can often be embarrassed to talk about problems they might be having ‘down there’. But vulval discomfort is common, affecting up to 7% of women, so this week we summarise how to identify and manage common vulval conditions.

A woman’s vulva is arguably the most intimate part of her body, and women can often be embarrassed to talk about problems they might be having ‘down there’. But vulval discomfort is common, affecting up to 7% of women in one study (BMJ 2012;344:e1723), and can have a significant impact on quality of life, psychological wellbeing and sexual function.

As health professionals, we need to be aware of the other vulval dermatoses, and know how to spot them and advise women on management. BASHH and the British Association of Dermatologists have provided guidance on symptom relief for vulval conditions, and the European Academy of Dermatology and Venereology (EADV) has written a helpful guideline for the identification and management of common vulval conditions. Click PDF to read our summary.

Chronic pain. If the drugs don’t work, then what can we offer instead?

26 Nov 2020

We know that we should be encouraging patients with long-term pain conditions to ‘self-manage’ or ‘self-care’. But how can we best do this? Click here for a clip from our chronic pain webinar, and click PDF for our full article on helping patients get active.

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Chronic pain. If the drugs don’t work, then what can we offer instead?

We know that we should be encouraging patients with long-term pain conditions to ‘self-manage’ or ‘self-care’. But how can we best do this? Click here for a clip from our chronic pain webinar, and click PDF for our full article on helping patients get active.

We know our traditional biomedical model is unhelpful when understanding and explaining chronic pain. We know that most of our pain medications are at best pretty ineffective, and at worst downright harmful. We know that we should be encouraging patients with long-term conditions to ‘self-manage’ or ‘self-care’. And yet, for me, there is a real knowledge gap between knowing I should be doing this and knowing how to do this in the best way. What can we offer instead?

Live Well With Pain is a fantastic online resource to help clinicians support their patients to better self-manage their long-term pain condition. It outlines 10 ‘footsteps’ patients can take towards this goal. Our Pearl this week is focused on footstep number 5 – getting active! Regular activity builds confidence and improves an individual’s ability to manage their pain. It can be reassuring for persistent pain patients to know that getting active will be beneficial for them, even if activity and exercise was not a regular part of their lives previously.

If this feels like a knowledge gap for you, as it does for me, then you might find this short clip on how to start the conversation about exercise with a patient who has chronic pain useful (from our recent webinar in collaboration with Versus Arthritis). We’ve also included a link to some useful web resources in our article on Getting active from our MSK handbook, which you can work through with your patients.

We will be covering more on the management of chronic pain in our brand new MSK and Chronic Pain Together course live on 11 December.

Our one-day update course – great teaching meets a live interaction event from our award-winning studio! Join us on any of our live dates for polls and interaction with presenters, OR watch on demand whenever suits you. Click here to watch our video and find out more about Red Whale Together events.

Mental Health Microskills

19 Nov 2020

This week, instead of sharing a NICE guideline or the latest PCN DES targets, we want to press ‘pause’ on your stress and take some time to work out what you really need, right now, to face the rest of your day. Click here to watch our mindful pause video and click PDF for our Expanding Perspectives article.

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Mental Health Microskills

This week, instead of sharing a NICE guideline or the latest PCN DES targets, we want to press ‘pause’ on your stress and take some time to work out what you really need, right now, to face the rest of your day. Click here to watch our mindful pause video and click PDF for our Expanding Perspectives article.

How many plates have you got spinning right now? Patients waiting, scripts piling up, results to check, and that’s before you start to think about taking the cat to the vet and mending the washing machine that isn’t draining properly because you haven’t cleaned the filter since – well, ever, really!

This week, instead of sharing a NICE guideline or the latest PCN DES targets, we at Red Whale want to share a pause. Just stop. Take a breath. Press ‘pause’ on your stress and take some time to work out what you really need, right now, to face the rest of your day. Lee David is going to talk you through a mindful pause in our video and then, if you feel stuck in a rut of negative thinking, you can use our ‘primary care microskill’ on expanding your perspective to help you find a way through that sticky patch. The Mental Health Update Together course is available on 4 December and is packed full of really useful and pragmatic skills (just like this one) that we can use for ourselves and our patients to take the sting out of our working days.

Our one-day Mental Health Update course – now with live interaction from our award-winning studio! Join us live for polls and interaction with presenters, OR watch on demand whenever suits you. Click here to watch our video and find out more about Red Whale Together events

Cancer early diagnosis and quality improvement

12 Nov 2020

In the UK, significant progress has been made in the past decade in improving rates of early diagnosis and treatment for cancer patients. Click here to watch our video on early diagnosis pitfalls and click PDF for full article.

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Cancer early diagnosis and quality improvement

In the UK, significant progress has been made in the past decade in improving rates of early diagnosis and treatment for cancer patients. Click here to watch our video on early diagnosis pitfalls and click PDF for full article.

In the UK, significant progress has been made in the past decade in improving rates of early diagnosis and treatment for cancer patients. But the impact of the COVID-19 pandemic has been wide ranging, and one of the unintended consequences of lockdown and the temporary change in delivery of health services has been the impact on cancer screening and diagnosis.

Remote consulting, less continuity of care and fewer visual clues mean we have to work harder and more deliberately to avoid those pitfalls that might cause us to miss an underlying cancer. We can think of these pitfalls in terms of 3 categories:

  • Red flags that are easily missed.
  • False reassurance from investigations.
  • Safety-net failures.

In addition, Early Diagnosis now has its own QOF domain, and many of us are participating in the PCN DES, one aspect of which focuses on earlier diagnosis of cancer. We look more closely at this issue on our Cancer Update Together course, and think about ways to support this work. Join us on our live dates for polls and interaction with presenters, OR watch on demand whenever suits you. Click here to watch our video and find out more about Red Whale Together events.

Take the genital herpes Mini Quiz

05 Nov 2020

Genital herpes is a common and distressingly painful condition that continues to be surrounded by significant social stigma and misunderstanding. Try our herpes mini-quiz to see if you know the top 8 facts about genital herpes.

More info PDF

Take the genital herpes Mini Quiz

Genital herpes is a common and distressingly painful condition that continues to be surrounded by significant social stigma and misunderstanding. Try our herpes mini-quiz to see if you know the top 8 facts about genital herpes.

Genital herpes is a common and distressingly painful condition that continues to be surrounded by significant social stigma and misunderstanding. It can have serious consequences (for example, neonatal herpes) but for most is mild and easily treated. As health professionals, it helps if we can use sensitive language to reassure and inform our patients of the implications of their diagnosis. But to be able to do this, we need the facts at our fingertips, and it is surprising how many of those herpes myths have trickled down into our own understanding. Try our herpes mini-quiz to see if you know the top 8 facts about genital herpes – can you beat the delegates on our Women’s Health Course? Then, reinforce your learning by clicking 'PDF' to read the full article.

Blurred vision

29 Oct 2020

Ophthalmology feels like one of those bits of clinical practice where your training never really prepared you for the reality of what might walk through your door.

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Blurred vision

Ophthalmology feels like one of those bits of clinical practice where your training never really prepared you for the reality of what might walk through your door.

Ophthalmology feels like one of those bits of clinical practice where your training never really prepared you for the reality of what might walk through your door. Your flight, fight or freeze mechanism kicks in, making objective assessment of the patient in front of you that bit harder! Just how should I set the dial on the ophthalmoscope anyway? Click PDF to see the blurred vision GEMS for more detail. 

Osteonecrosis of the jaw

22 Oct 2020

Have you ever actually seen a case of osteonecrosis of the jaw? Would you know how to recognise the warning signs, or how your patients could minimise their risk? Click here to watch a ‘Whale Art’ highlighting some of these issues.

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Osteonecrosis of the jaw

Have you ever actually seen a case of osteonecrosis of the jaw? Would you know how to recognise the warning signs, or how your patients could minimise their risk? Click here to watch a ‘Whale Art’ highlighting some of these issues.

Osteoporosis awareness day fell on 20 October this year. In primary care, this is bread and butter stuff (albeit complicated bread and butter, with some pretty big unanswered questions remaining!). We start bisphosphonates for osteoporosis prevention or treatment, and provide information to our patients on their possible side-effects. But have you ever actually seen a case of osteonecrosis of the jaw? Would you know how to recognise the warning signs, or how your patients could minimise their risk? – click through from the PDF button below to read our article.

Complaints and how we can manage ourselves better when we receive them

15 Oct 2020

Complaints are an inevitable part of our working lives. But how can we manage ourselves better when we receive them?

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Complaints and how we can manage ourselves better when we receive them

Complaints are an inevitable part of our working lives. But how can we manage ourselves better when we receive them?

Complaints: an inevitable part of our working lives. Pressurised clinics, sudden changes in ways of working and unprecedented workload over the past few months may well have increased the number of complaints you are handling, and this can add significantly to your stress levels. So how can we manage this better?

Temperature measurements in children

08 Oct 2020

A BJGP study revealed that non-contact infrared thermometers in the under-5s showed >1°C variation in temperature readings when compared with tympanic temperature. This is a reminder that temperature should be one element in a holistic assessment of a child!

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Temperature measurements in children

A BJGP study revealed that non-contact infrared thermometers in the under-5s showed >1°C variation in temperature readings when compared with tympanic temperature. This is a reminder that temperature should be one element in a holistic assessment of a child!

“School has bought one of those clever all-singing, all-dancing infrared thermometers to screen the children’s temperatures before they go in – it’s amazing! But this morning, they told me his temperature was 34.3°C and that it was dangerously low, so I should bring him to see you urgently. He looks fine. What should I do?”

A BJGP study revealed that non-contact infrared thermometers in the under-5s showed >1°C variation in temperature readings when compared with tympanic temperature. Perhaps we should encourage parents to use tympanic thermometers! This is also a reminder to us all that temperature should be one element in a holistic assessment of a child!

Inflammatory Arthritis

01 Oct 2020

We have teamed up with Versus Arthritis to share with you this PEARL on how to spot inflammatory arthritis, and differentiate it from the much more common conditions of osteoarthritis and the 'aches and pains of everyday life.'

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Inflammatory Arthritis

We have teamed up with Versus Arthritis to share with you this PEARL on how to spot inflammatory arthritis, and differentiate it from the much more common conditions of osteoarthritis and the 'aches and pains of everyday life.'

Diagnosing inflammatory arthritis early matters but can sometimes be tricky, particularly at the moment. A national audit in 2016 showed that many patients are waiting too long to have their diagnosis confirmed. The reverse side of the coin is that research has led to significant improvements in treatment in recent years and a concept of aiming for ‘total control’.

We have teamed up with Versus Arthritis to share with you this PEARL on how to spot inflammatory arthritis, and differentiate it from the much more common conditions of osteoarthritis and the 'aches and pains of everyday life.'

If we are successful in spotting patients in the early golden window, they have a much better prognosis in terms of joint damage, persistent pain and disability.

It is less complex than we might think! A good clinical history, a hint of pattern recognition and a focused examination will give us most of the information we need, and a top tip: blood tests should not rule out a diagnosis of inflammatory arthritis in primary care! So, if you are feeling a bit rusty after months of telephone calls about potential COVID-19 symptoms, read on to brush-up.


And join us for our FREE webinar, ‘Inflammatory arthritis: early diagnosis and total control – what can we do in primary care?’, which will be available on demand from Thursday 22 October. We will cover diagnosis; the role of blood tests and the current evidence around DMARD shared care; safe prescribing; the wider impact of the diagnosis on health; and holistic support for inflammatory arthritis patients. We will also specifically look at referral criteria for spondyloarthritis, an area where we may be missing young patients with inflammatory back pain.

Diabetes new technology

24 Sep 2020

Achieving tight glycaemic control in diabetes is a keystone of good management for most patients. But, as healthcare professionals, it can be hard to stay up to date with all the changes.

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Diabetes new technology

Achieving tight glycaemic control in diabetes is a keystone of good management for most patients. But, as healthcare professionals, it can be hard to stay up to date with all the changes.

Achieving tight glycaemic control in diabetes is a keystone of good management for most patients. But, as healthcare professionals, it can be hard to stay up to date with all the changes. Keeping up with the rapidly expanding list of medication options can feel hard enough, but what about the new technologies? Do you know your ‘Flash’ from your ‘CGM’? And what’s the difference between a pump and an artificial pancreas?

In 2019, NHS England and NHS Improvement published a commitment to end the variation in availability of these technologies across the NHS, so we are likely to see an increase in their use. For all these devices, the principle of self-management and improved patient control over their own condition is paramount. In primary care, we are unlikely at this stage to be making the decision to start these treatments, but we may well be asked to take over prescribing, or see patients who have bought their own kit asking us to support their use.

Delirium: the warning sign we don’t want to miss for our more frail patients

17 Sep 2020

Delirium is an important presenting feature or ‘barometer’ of acute illness in our elderly patients, but it can be a challenge to diagnose! And it is both common and serious.

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Delirium: the warning sign we don’t want to miss for our more frail patients

Delirium is an important presenting feature or ‘barometer’ of acute illness in our elderly patients, but it can be a challenge to diagnose! And it is both common and serious.

Delirium is an important presenting feature or ‘barometer’ of acute illness in our elderly patients, but it can be a challenge to diagnose! It is common: prevalence in the community in the over-85s may be as high as 14%. And it is serious: patients diagnosed with delirium during a hospital admission are twice as likely to die in the next 12 months.

During this pandemic, more than ever, it is important that we are aware of the diagnosis and how not to miss it. Some studies have shown that 20–30% of COVID-19 infections will present with or develop signs of delirium during the course of the illness (Age and Ageing 2020 49;4:497). Older adults do not always mount the typical febrile response we might see in infection, and there is therefore a risk of missing potentially-reversible causes for our patients’ deteriorating condition. In addition, the unique circumstances of lockdown – isolation, heightened anxiety and a loss of control over normal life – will all increase the risk of delirium developing.

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.

We should use a validated tool to check for delirium, then assess for all possible causative factors and reverse/treat these. The mnemonic HIDDEN CAUSE might help you remember the common causes of delirium (HIDDEN), and important predisposing factors (CAUSE). Those in italics are associated with hypoactive delirium.
 

Hypoxia Hypo/hyperthermia     

Infection             

Dehydration (or malnutrition)    

Drugs, drug withdrawal, polypharmacy  

Electrolyte or metabolic disturbance        

No poo (constipation!)  

 

Comorbidity including pre-existing cognitive impairment

Age (increasing) and Alcohol abuse

Urinary catheter

Sleep deprivation

Environmental issues (sensory deprivation, social isolation)
 

Our Pearl this week includes details on how to identify delirium using tools like the Confusion Assessment method and the 4AT; how to spot the hidden causes of delirium; and up-to-date guidance on the management of delirium in line with NICE guideline CG103. Click PDF to read article.

“Can I have an ambulance?” “Yes, if you give me the NEWS2.”

10 Sep 2020

Sepsis awareness day is 13 September and this week's Pearl includes content from our upcoming autumn GP Update courses.

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“Can I have an ambulance?” “Yes, if you give me the NEWS2.”

Sepsis awareness day is 13 September and this week's Pearl includes content from our upcoming autumn GP Update courses.

Ever been flummoxed by an answer like this? Or are you a convert and using NEWS2 regularly?

NEWS2 is a way of assessing patients based on 5 physiological parameters, whether they are on oxygen and whether any confusion/altered consciousness is present. It isn’t just for sepsis!

It has been around for a while as a hospital-based scoring tool, but now research has shown that when primary care uses NEWS2:

  • People are transported to hospital by ambulance more quickly and are seen more quickly.
  • It may identify people with suspected sepsis better and may improve prognosis.

Our Autumn 2020 GP Update online courses will contain all the detail on how to use this scoring tool, but, in the meantime, this week’s Pearl is a reminder of the NICE guidelines on sepsis, including a handy colour chart to help you stratify the clinical indicators in your sick patient. Feel free to print this out and share it with your wider team!

But NEVER let clinical judgement be trumped by a score. If you are worried, act. Clinical instinct, experience, gut feeling – whatever you want to call it – should never be ignored!

Cough in the returning traveller - but, what if it’s NOT COVID?!

03 Sep 2020

In this week’s Pearl, we have summarised the 2019 NICE guidance on tuberculosis, picking out the aspects relevant to us in primary care.

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Cough in the returning traveller - but, what if it’s NOT COVID?!

In this week’s Pearl, we have summarised the 2019 NICE guidance on tuberculosis, picking out the aspects relevant to us in primary care.

My patient had just returned from a trip to visit her family in India. She had a cough, fever and malaise. I confidently sent her off for a COVID-19 test, and advised self-isolation, and not to return to her role in a local care home until her test results were back. But her COVID test was negative, and three weeks later she was still coughing. A CXR revealed signs suggestive of pulmonary TB, which prompted further testing and a referral to my local respiratory team, as well as a variation on my usual referrals to PHE!

The filter of a global pandemic can affect our diagnostic lens, but not all that coughs is COVID, and this case was a timely reminder to me to remain alert to the other infectious causes of chronic cough.

TB is not something we will be managing without specialist input, but we need to be aware of the possibility of the diagnosis, and the relevant tests and treatment regimens. In this week’s Pearl we have summarised the 2019 NICE guidance on tuberculosis, picking out the aspects relevant to us in primary care.

Click PDF to read our article.

When that 'Back to School' feeling isn’t so great: anxiety in children and young people

27 Aug 2020

September is around the corner and for most of us working in primary care, whatever our role, the summer may not have been quite as rejuvenating as usual.

More info PDF

When that 'Back to School' feeling isn’t so great: anxiety in children and young people

September is around the corner and for most of us working in primary care, whatever our role, the summer may not have been quite as rejuvenating as usual.

This is also true for many of our children and the children of our patients. The 'Back to School' feelings may be tinged with more than the usual amount of anxiety. Anxiety is incredibly common in children and young people and, for many, it is transient and self-limiting.

 

So, how do we spot when anxiety in children is part of 'normal' and when does it start to become a problem, and something that needs support and intervention? What simple low level strategies might work and when should we refer? How can we explain anxiety to different age groups?

 

This week we offer you an article from the Child and Adolescent section of our mental health course 'Anxiety in children and young people'. Click PDF to read the article.

Diagnosing cancer: ‘soft markers’ and how they can help us

20 Aug 2020

One tool we have at our disposal is spotting ‘softer markers’ of possible cancers, and thrombocytosis has been a big story over the past few years. This week’s PEARL shares an approach to tackling raised platelets (whether they are caused by cancer or not!). 

More info PDF

Diagnosing cancer: ‘soft markers’ and how they can help us

One tool we have at our disposal is spotting ‘softer markers’ of possible cancers, and thrombocytosis has been a big story over the past few years. This week’s PEARL shares an approach to tackling raised platelets (whether they are caused by cancer or not!). 

The long-term plan for cancer is ambitious. It was ambitious before COVID-19. It is really ambitious now. It aims to ensure that by 2028, 55,000 more people (nationally) will survive cancer for 5 years or more each year, and that 75% of people will be diagnosed at stage one.

During lockdown, the rate of referrals via urgent two-week-wait pathways dropped by up to 75% per week. Turning this tap back on will need committed shared effort across all healthcare settings. Despite direct funding for cancer care seen in both QoF and the PCN DES, primary care needs support if there is any hope of implementing this in the context of our current workload.

This autumn, we will have a big focus on early cancer diagnosis as part of our GP Update and Primary Care Cancer Update courses. We will offer a really pragmatic pitfalls-based approach and lots of support to make implementing the DES and QOF effective and as easy as possible.

One tool at our disposal is spotting ‘softer markers’ of possible cancers, and thrombocytosis has been a big story over the past few years. This week’s PEARL shares an approach to tackling raised platelets (whether they are caused by cancer or not!); we hope the flowchart is useful – do feel free to print it out, share it with colleagues and laminate it!

Click PDF to read our article.

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