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Troubleshooting hypothyroidism – what to do when the numbers and the story just don’t add up!

17 Jun 2021

Managing hypothyroidism might seem easy: diagnose, start levothyroxine and – once the results show the treatment is working – sit back and check the bloods once a year. Or maybe not.

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Troubleshooting hypothyroidism – what to do when the numbers and the story just don’t add up!

Managing hypothyroidism might seem easy: diagnose, start levothyroxine and – once the results show the treatment is working – sit back and check the bloods once a year. Or maybe not.

Many of us will be able to think of times when things didn’t quite go to plan when managing hypothyroidism! In the past month, I have managed one patient who, over the years, has swung from being hypothyroid to being hyperthyroid (off drugs), and another who has been totally stable on one dose of levothyroxine for over 15 years, only to suddenly present with a sky-high TSH and symptoms – seemingly without any obvious explanation.

So, what should we do in these trickier cases? What drugs might be affecting your patient’s thyroid blood results? And what if they can’t stop taking those drugs? What if, despite normalizing the TSH, they remain symptomatic? We cover all these issues and more in our GEMS (Guidelines and Evidence Made Simple) on hypothyroidism. Click PDF to read our GEMS.

Can you still prescribe chloramphenicol drops to under 2's?

10 Jun 2021

“Nursery have just told me that Jonny (18m) can’t come back until he has drops for his sticky eyes.” But can you still prescribe those chloramphenicol drops? In April 2021, the Royal College of Ophthalmologists issued a safety alert on the use of chloramphenicol eye drops in children under 2 years of age.

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Can you still prescribe chloramphenicol drops to under 2's?

“Nursery have just told me that Jonny (18m) can’t come back until he has drops for his sticky eyes.” But can you still prescribe those chloramphenicol drops? In April 2021, the Royal College of Ophthalmologists issued a safety alert on the use of chloramphenicol eye drops in children under 2 years of age.

In April 2021, the Royal College of Ophthalmologists issued a safety alert on the use of chloramphenicol eye drops in children under 2 years of age (Safety Alert: Boron additives in Chloramphenicol drops; should ophthalmologists be concerned? - The Royal College of Ophthalmologists (rcophth.ac.uk)).

So, what is the concern here?

Chloramphenicol eye drops contain boron, and some animal studies have shown links with reduced fertility at even quite low doses. As a result, the European Medicines Agency has advised safe upper limits for exposure to boron-containing medicines, and chloramphenicol eye drops are no longer licensed for children under 2 years of age. The MHRA is yet to issue guidance on this issue for us in the UK.

It is important to note that chloramphenicol eye ointments are not affected by this advice.

The Royal College of Ophthalmology also reminds us that even at maximum doses of chloramphenicol eye drops, the dose of boron would still fall well below EMA safe levels, so there may be an element of over-caution being applied here! We think the RCO advice is very balanced and worth a read.

Do we need to prescribe antibiotics at all?

In conjunctivitis, in both adults and children, antibiotics may offer a small benefit, but it is in the region of being better 6h sooner on day 5 of the illness. And not treating resulted in no extra adverse events in the trials. Treating with antibiotics did, however, increase the chance of people coming back next time to ask for more antibiotics!

The Health Protection Agency says that children do not need to be excluded from day care/nursery/school because of conjunctivitis. If your local nursery suggests anything other than this, send them a copy of the HPA guidance and ask them to update their policies!

Hypertension: does age matter when choosing the first antihypertensive?

03 Jun 2021

With QOF back on (in England at least), we need to start thinking about those blood pressure targets and making sure we have achieved good control for our patients. But which drug should we choose, and should age matter when we make that decision?

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Hypertension: does age matter when choosing the first antihypertensive?

With QOF back on (in England at least), we need to start thinking about those blood pressure targets and making sure we have achieved good control for our patients. But which drug should we choose, and should age matter when we make that decision?

Once diabetes and ethnicity have been taken into account, NICE recommends that ACE inhibitors are used as first-line therapy in those <55y, and calcium channel blockers (CCBs) in those ≥55y.

However, a UK cohort study showed that:

• In those who were not black, not diabetic and <55y (i.e. where NICE recommends ACE inhibitor first line), there was no significant difference in BP control between ACE inhibitors or CCBs at 12 months.

• CCBs did seem to have greater BP-lowering effects in those over 75y.

What does this mean in practice?

Most international guidance does NOT include age as a factor when deciding on which drug to use.

It may be that we should think more about other comorbidities – for example: hypertension + proteinuria = choose ACE inhibitor; hypertension + CVA = choose CCB. As we manage hypertension and follow NICE, remember that guidelines are written for populations, and if there is a good reason to deviate for a specific person then we are free to do that (just remember to document it so it can be justified at a later date!).

Chronic pain: NICE guidance

27 May 2021

The new NICE guidance on chronic pain represents an opportunity for real change in practice and improved care, particularly for those with chronic primary pain. The calls to action reach way beyond primary care but there are some things we can do to help our patients.

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Chronic pain: NICE guidance

The new NICE guidance on chronic pain represents an opportunity for real change in practice and improved care, particularly for those with chronic primary pain. The calls to action reach way beyond primary care but there are some things we can do to help our patients.

The new NICE guidance on chronic pain, released last month, represents an opportunity for real change in practice and improved care for people experiencing all types of chronic pain, particularly those with chronic primary pain. We cannot do all of this in primary care. In order to tackle the complex web of social and societal issues and inequalities that make living with chronic pain so difficult, the calls to action reach way beyond primary care. But there are some things we can do to offer support and understanding, and to minimise harm while we wait for (or influence) care pathways to catch up.

In this Pearl, we look at the nuts and bolts of the new NICE guideline, including:

  • The difference between chronic primary and secondary pain – when the definitions matter and when they don’t!
  • How to assess people with ALL types of chronic pain.
  • How to manage people with chronic primary pain, including LOTS of things we can do, plus those we should not do!


Click PDF to read our article on Chronic pain: NICE guidance.

And if you want to learn more, or would like the opportunity to ask questions, we’ve teamed up with Versus Arthritis to offer two special FREE webinars on this topic. Join Dr Giles Hazan (GPwER in Chronic Pain) and Dr Benjamin Ellis (Consultant Rheumatologist who sat on the NICE committee that wrote this guideline) LIVE on the Red Whale sofa on Friday 4 June at 13:00 for our webinar on the NICE chronic pain guidelines.

 

This will be followed by a further ON DEMAND webinar on practical tips and skills on what we can do in for chronic pain patients primary care; this will be available from Wednesday 7 July. Please, share these links with any clinical members of your primary care team who you think might be interested – everyone is welcome!

Croup: dexamethasone or prednisolone?

20 May 2021

Having seen hardly any of the usual influx of snotty kids over winter, my practice is suddenly dealing with an enormous number of preschoolers with viral URTI presentations. And from a quick glance at the GP press, I see we are not alone!

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Croup: dexamethasone or prednisolone?

Having seen hardly any of the usual influx of snotty kids over winter, my practice is suddenly dealing with an enormous number of preschoolers with viral URTI presentations. And from a quick glance at the GP press, I see we are not alone!

Croup is just one example of those conditions, and it can be tricky to balance the risks in primary care. Parents come in exhausted after a long night with a child who looks pretty well, and yet you know they are in for another few rough nights before things improve. Could a single dose of steroids make a difference?

A single dose of dexamethasone is traditionally recommended for croup at 0.15mg/kg but is often not available on the same day in community pharmacies.

Prednisolone is widely available in community pharmacies – but does it work?

Yes!

• Prednisolone 1mg/kg is as good as dexamethasone.

• Children are no more likely to need a second dose either (half-life of prednisolone is substantially shorter than dexamethasone, and so it was thought a second dose would be needed).

Clearly, you also need to safety-net so parents know when to call for help if things do get worse in the night.

Click PDF to read our full Pearl article.

Our take on 'Sex, myths and the menopause'

13 May 2021

Sex, myths and the menopause: new Davina McCall documentary tackles the taboos around menopause and encourages women to seek help for their symptoms. Our Pearl this week is all about helping you to help them when they do!

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Our take on 'Sex, myths and the menopause'

Sex, myths and the menopause: new Davina McCall documentary tackles the taboos around menopause and encourages women to seek help for their symptoms. Our Pearl this week is all about helping you to help them when they do!

Almost all women will experience some form of symptoms at the time of their menopause. For most, these will be mild, but for some, they can be debilitating – affecting home life, work and relationships. TV presenter Davina McCall is taking an honest look at her own experience in a new Channel 4 documentary released on 12 May 2021. Perhaps women will contact us after seeing the documentary, and we want to be ready to help in an evidence-based, informed and holistic way.

For those of us working in primary care, managing menopausal symptoms can feel like a bit of a minefield. Many women receive great menopause care, but it isn’t always easy. We need to juggle concerns about safety; work out which symptoms belong to the menopause and which need treating with medication; work out when to offer lifestyle advice (and what to advise!); decide who needs referral to a specialist; establish which regime of HRT is appropriate for the patient in front of us; and, after all that, we then need to tackle longstanding HRT supply issues!

Red Whale Women’s Health course presenters, Lucy Cox and Helen Barnes, will be talking about the documentary and discussing some of these issues with presenter Nik Kendrew in the BoggledDocs podcast this week. For those of you who aren’t familiar with it, BoggledDocs is a podcast for primary care professionals which takes a light-hearted look at medical stories in the media to help you target your CPD.

If the podcast reminds you that learning more about HRT is on your CPD action plan, Red Whale is here to help! Our Pearl this week is sharing our HRT GEMS summary – 3 pages packed with vital information on all things related to menopause and HRT to help you find the right HRT ‘recipe’ for each woman. Feel free to share this with your colleagues.

And coming up later in 2021, Red Whale will be running a half-day update course on all things menopause.

Your questions answered - cancer early diagnosis

06 May 2021

Around 50% of cancers are currently detected at stage 1/2 and the NHS Plan has set a target of 75% by 2028. Part of the challenge is to get patients to make the initial appointment to discuss a symptom that could be cancer. How can we influence them to present sooner?

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Your questions answered - cancer early diagnosis

Around 50% of cancers are currently detected at stage 1/2 and the NHS Plan has set a target of 75% by 2028. Part of the challenge is to get patients to make the initial appointment to discuss a symptom that could be cancer. How can we influence them to present sooner?

Week 4, the final week of our Red Whale Round-up – our look back at some of the frequently-asked questions from our online GP Update Together courses over autumn 2020 and winter 2021. A really important topic we discussed in these courses was the early diagnosis of cancers. The NHS Plan has set a target of detecting 75% of cancers at stage 1 or 2 by 2028. At the moment in the UK, about 50% are detected at this stage so we have some way to go. We talked about the ‘softer‘ blood test markers that might help us clinically to spot cancers at an earlier stage, but, of course, patients have to choose to make that initial appointment to discuss a symptom that could be cancer. What influences them, and how can we influence them to present sooner? We would like to share with you our summary of evidence from recent years.

Your Questions Answered - Diabetes & Intermittent Fasting

29 Apr 2021

In terms of helping our diabetes patients, low-carbohydrate diets seem promising, but what about intermittent fasting? This was a frequently asked question from colleagues on our winter GP Update courses, so this week we look at the evidence from a 2020 NEJM review.

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Your Questions Answered - Diabetes & Intermittent Fasting

In terms of helping our diabetes patients, low-carbohydrate diets seem promising, but what about intermittent fasting? This was a frequently asked question from colleagues on our winter GP Update courses, so this week we look at the evidence from a 2020 NEJM review.

It’s week 3 of our Red Whale round-up Pearls that look back at the frequently asked questions on our winter GP Update Together courses. And, this week, diabetes! We spent some time talking about which diet might work best to help our patients with diabetes get their blood sugars under control. Low-carbohydrate diets seem promising, but what about intermittent fasting? Patients often ask us about it, and you asked about it on our winter courses, so let’s look at the evidence from a 2020 NEJM review in more detail (NEJM 2020;381:26:2541).

Your questions answered - the environmental impact of inhalers

22 Apr 2021

It's our second week of our ‘Red Whale Round-up’ – where we take a look back at some of the common questions on our winter GP Update Together courses. Watch Nik introduce this week's topic - the impact of inhalers on the environment.

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Your questions answered - the environmental impact of inhalers

It's our second week of our ‘Red Whale Round-up’ – where we take a look back at some of the common questions on our winter GP Update Together courses. Watch Nik introduce this week's topic - the impact of inhalers on the environment.

Traditional metered-dose inhalers carry an environmental harm due to the propellants used within them, so how can we make choices as prescribers to reduce these harms? Click PDF to read our article on the true impact of our prescribing choices, and you might also like to look at how your area is doing on this issue by checking Open Prescribing for its analysis Environmental Impact of Inhalers by all CCGs | OpenPrescribing.

Budesonide for acute community COVID-19 - The low down

15 Apr 2021

BBC Headline “Covid: Asthma drug ‘speeds up recovery at home’.” To say that there has been a lot written about COVID-19 in the past 12 months would be the understatement of the year, and in primary care we are getting used to hearing major new changes in practice on the news rather than from our usual sources.

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Budesonide for acute community COVID-19 - The low down

BBC Headline “Covid: Asthma drug ‘speeds up recovery at home’.” To say that there has been a lot written about COVID-19 in the past 12 months would be the understatement of the year, and in primary care we are getting used to hearing major new changes in practice on the news rather than from our usual sources.

It seems we are now being asked to consider prescribing inhaled corticosteroids to people in the community with acute COVID-19. 

So, the BBC press release corresponded with a note from the CMO (it may be lingering in your inbox). While the headline is true, the nuance of the CMO letter and evidence is slightly different!
For those who need a quick answer:

  • Budesonide is not currently recommended as standard care.
  • Its use can be considered as part of a shared decision for people within 14 days of PCR confirmed COVID-19 with ongoing symptoms who are:
    • 65y or older
    • 50y or older with co-morbidities making them eligible for influenza vaccination.
  • If prescribing use Pulmicort Turbohaler 400mcg 2 puffs twice daily (total dose 1600 mcg).
  • Alternatives are available if there are supply problems. 
  • It should be used for a maximum of 14 days or until the inhaler runs out/symptoms resolve.
  • The bottom line is that it appears to reduce duration of symptoms by median 3 days (1-5 days) and may have an impact on hospitalisations/ urgent care but this is less certain.

Click on the PDF button to read this week’s PEARL and dig behind the headline.

Your questions answered - new NICE VTE guidance

08 Apr 2021

We're rounding up the most common questions from our autumn/winter GP Update season. Watch Nik's intro video to this week's topic - venous thromboembolism and the changes in NG158 2020 NICE guidance on VTE. 

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Your questions answered - new NICE VTE guidance

We're rounding up the most common questions from our autumn/winter GP Update season. Watch Nik's intro video to this week's topic - venous thromboembolism and the changes in NG158 2020 NICE guidance on VTE. 

VTE was always a topic that generated a lot of discussion and debate on our Together courses. There were 2 common questions that had you scratching your heads:

  • Can we use DOACs to treat VTE in patients with active cancer?
  • Age adjustment for D-dimer: when do we do it? And how?

Click PDF to read our Pearl, where we give our answers to these questions.

Rashes in Pregnancy

01 Apr 2021

Rashes in pregnancy are a common presentation that can make us worry. What should we do when a pregnant woman comes into contact with an infectious rash? Click PDF to read our summary.

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Rashes in Pregnancy

Rashes in pregnancy are a common presentation that can make us worry. What should we do when a pregnant woman comes into contact with an infectious rash? Click PDF to read our summary.

What should we do when a pregnant woman comes into contact with an infectious rash? What counts as significant exposure? When can we consider a woman immune based on her past medical and vaccination history? When should we offer testing?

Video Pearl - Contraception for women over 40

25 Mar 2021

In the perimenopause, it can be tricky to differentiate menopausal symptoms from those caused by something else, particularly if the woman is taking hormonal contraception. Click here to watch our video and click PDF to read our article.

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Video Pearl - Contraception for women over 40

In the perimenopause, it can be tricky to differentiate menopausal symptoms from those caused by something else, particularly if the woman is taking hormonal contraception. Click here to watch our video and click PDF to read our article.

As women reach their forties, and particularly as they approach their fifties, natural fertility declines and perimenopausal symptoms can begin.

In the perimenopause, it can sometimes be tricky to work out which symptoms are due to menopause and which might be due to something else, particularly if the woman is taking hormonal contraception. Women may also be confused about when they no longer need contraception, and may assume they are too old to get pregnant. So, when is it helpful to check an FSH? And which of those hormonal medications might affect the result? Here is a sneak preview of our women’s health course, where Lucy Cox takes a closer look at this issue.

The FSRH has drawn up some guidelines on the management of contraception in the reproductively-older and perimenopausal woman (FSRH Contraception for women aged >40, 2017, click PDF to read our article summarising its advice).

If women’s health is on your PDP this year, you might find our online women’s health course helpful. Get confident with gynaecological consultations! You don’t need to have a special interest to attend but, if you do, the course fulfils the CPD criteria for DFSRH/DFFP LoC IUD/SDI.

 

Weight Loss as a Predictor of Cancer

18 Mar 2021

A recent BJGP meta-analysis examined the diagnostic value of recorded weight loss, alone and in combination with other clinical features, as a predictor of cancer in primary care patients. This week we summarise the useful messages in it for primary care.

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Weight Loss as a Predictor of Cancer

A recent BJGP meta-analysis examined the diagnostic value of recorded weight loss, alone and in combination with other clinical features, as a predictor of cancer in primary care patients. This week we summarise the useful messages in it for primary care.

As primary care clinicians, unexplained weight loss can be a challenging symptom, especially if it occurs in isolation. It can be an indicator of cancer, but also many non-cancer conditions. There are no national guidelines on how to manage isolated weight loss, and often no clear referral pathways, leaving us with uncertainty about how to manage and when/where to refer.

A recent BJGP meta-analysis examined the diagnostic value of recorded weight loss, alone and in combination with other clinical features, as a predictor of cancer in primary care patients. It also examined how the predictive value of weight loss varies by cancer type, cancer stage, sex and age. There are some useful messages for us in primary care, which we have summarised in our Pearl this week.

Juvenile Idiopathic Arthritis

11 Mar 2021

Juvenile idiopathic arthritis (JIA) is more common than we might realise, affecting the same proportion of children as type 1 diabetes or childhood epilepsy. In the absence of trauma or infection, it is the most likely cause of a single swollen joint lasting more than 6 weeks in children.

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Juvenile Idiopathic Arthritis

Juvenile idiopathic arthritis (JIA) is more common than we might realise, affecting the same proportion of children as type 1 diabetes or childhood epilepsy. In the absence of trauma or infection, it is the most likely cause of a single swollen joint lasting more than 6 weeks in children.

We have teamed up with Versus Arthritis to share with you this Pearl on how to spot juvenile idiopathic arthritis, and differentiate it from other causes of childhood joint pain.

Juvenile idiopathic arthritis (JIA) is more common than we might realise, affecting the same proportion of children as type 1 diabetes or childhood epilepsy. In the absence of trauma or infection, it is the most likely cause of a single swollen joint lasting more than 6 weeks in children.

It is often diagnosed relatively late as the initial signs may be subtle. We may simply see changes in behaviour, especially in very young children who cannot verbalise pain. 

But diagnosis is less complex than we might fear! A good clinical history, a hint of pattern recognition and a focused examination will give us most of the information we need. So, if you are feeling a bit rusty after months of telephone calls about potential COVID-19 symptoms, read on to brush-up.

Adverse Childhood Experiences

04 Mar 2021

Did you know that one factor is implicated in 7 out of 10 deaths in the USA? If exposed, your life expectancy may be shortened by up to 20 years and you have triple the risk of heart disease and lung cancer. What is it, I hear you ask?...Adverse childhood experiences

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Adverse Childhood Experiences

Did you know that one factor is implicated in 7 out of 10 deaths in the USA? If exposed, your life expectancy may be shortened by up to 20 years and you have triple the risk of heart disease and lung cancer. What is it, I hear you ask?...Adverse childhood experiences

I want to share with you something that I have become increasingly passionate about. This is not new; in fact, the study I want to share comes from 1998. But it lies at the heart of many of our most challenging tasks and consultations in primary care.

Did you know that one factor is implicated in 7 out of 10 deaths in the USA?

If exposed, your life expectancy may be shortened by up to 20 years and you have triple the risk of heart disease and lung cancer.

Based on these numbers, you would expect this to be a public health priority akin to sepsis…yet, despite an evidence base dating back 20 years, we don’t have automatic scores popping up on our computer, and most of us have had no training in how to identify or manage this problem.

What is it, I hear you ask?

Adverse childhood experiences …yes, that’s right... I don’t remember many lectures on this at medical school or questions in MRCGP exams!

Referrals to children’s social care fell by a fifth during the first lockdown (Children's social care referrals fell by a fifth during lockdown | Local Government Association). With many of society’s most vulnerable children out of school, there have been significant concerns about their wellbeing, and fears that we will see an increase in children exposed to adverse childhood experiences (ACEs) due to COVID-19 restrictions. We’ve summarised some of the evidence around ACEs, and some starting points in how to help people, in this week’s Pearl. We think the ACEs trial might just be the most important public health study you’ve never heard of.

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?

More info PDF

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.

More info PDF

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.

More info PDF

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.

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