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Raynaud's Phenomena

25 Nov 2021

As winter takes hold, one of the presentations we might see popping up is fingers turning white in the cold. At last, an easy consultation! We are thinking about Raynaud’s – but hang on… is this primary or secondary Raynaud’s?

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Raynaud's Phenomena

As winter takes hold, one of the presentations we might see popping up is fingers turning white in the cold. At last, an easy consultation! We are thinking about Raynaud’s – but hang on… is this primary or secondary Raynaud’s?

Isn’t it great when you know exactly what is wrong with the patient from the story alone?! It doesn’t happen as often as we might like. A common winter presentation is fingers turning white in the cold. We are thinking about Raynaud’s but how do we know if it is primary or secondary Raynaud’s? What tests should we think about doing? And what treatments should we advise?

Our Pearl this week looks back at a 2016 NEJM review on this topic and summarises the bits relevant to primary care. Click PDF to read our article.

The heating is back on. Is that a stress headache, or could it be carbon monoxide poisoning?

18 Nov 2021

As the heating goes back on across the country, our Pearl this week looks at the rare but important problem of carbon monoxide poisoning.

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The heating is back on. Is that a stress headache, or could it be carbon monoxide poisoning?

As the heating goes back on across the country, our Pearl this week looks at the rare but important problem of carbon monoxide poisoning.

At this time of year, we can get the urge to hibernate in a cosy living room. Approximately 50 people a year in the UK will die from confirmed carbon monoxide poisoning but many more will be affected.

In acute poisoning, symptoms will come on very rapidly. In primary care, we are more likely to see chronic carbon monoxide poisoning, with much more subtle signs developing over weeks to months. Spotting this easy-to-miss diagnosis is all about the history. Click PDF to read our summary of a 2019 BMJ review on this topic.

Shoulder pain

11 Nov 2021

Shoulder pain is common, affecting up to a quarter of adults at any one time. Being able to distinguish the red flags that should trigger onward referral is enormously valuable, and, surprisingly, more can be done remotely than you might think.

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Shoulder pain

Shoulder pain is common, affecting up to a quarter of adults at any one time. Being able to distinguish the red flags that should trigger onward referral is enormously valuable, and, surprisingly, more can be done remotely than you might think.

My final patient of the day, late last night, was an urgent appointment added as an extra. ‘Shoulder pain and swelling, fluid inside’ said the appointment notes completed by the reception team.

I picked up the phone but I already knew this person would be coming down – how could I effectively triage something like shoulder pain over the phone?

Our Pearl this week is focused on a great older paper from the BMJ (BMJ 2005;331:1124) which might revolutionise our approach to shoulder assessments.

The paper suggests 3 questions to ask in the history:

  1. Are there red flags?
  • Tumour: unexplained mass, deformity or swelling?
  • Infection: any erythema, fever or systemic illness?
  • Trauma: any risk of unreduced dislocation, disabling pain, significant weakness?
  • Nerves: any neurological changes?
  1. Is the pain coming from the shoulder, the neck or elsewhere (in the case of my patient last night, it was actually upper back pain!)?
  • Do movements of the neck or shoulder trigger upper back pain?
  1. Is the shoulder unstable?
  • Ask: are you worried your shoulder might slip with certain movements?; has it ever come out of joint?

Using this approach, we can reassure ourselves that the history has no concerning features, the pain is definitely in the shoulder, and the joint is not unstable. Click through to read our full article which describes how to distinguish symptoms originating from the AJ or glenohumeral joints, and how to work out exactly which rotator cuff muscle you are dealing with! And, if ‘MSK refresher’ is on your PDP this year, our brand new MSK course full of really practical hands-on primary care musculoskeletal medicine tips is being released on demand on November 22nd, ready for our live MSK Together event on Thur 25 Nov

COVID-19 vaccine impacts on menstrual cycle and concerns about fertility

28 Oct 2021

As the COVID-19 vaccine rollout continues, and children aged 12 and over are invited forward to receive their doses, we may find ourselves being asked about the impact of vaccination on young women’s menstrual cycles and fertility.

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COVID-19 vaccine impacts on menstrual cycle and concerns about fertility

As the COVID-19 vaccine rollout continues, and children aged 12 and over are invited forward to receive their doses, we may find ourselves being asked about the impact of vaccination on young women’s menstrual cycles and fertility.

False information about the vaccine impacting future fertility is widespread online. This can lead to vaccine hesitancy from girls and their parents. In addition, there have been reports that the vaccine might affect the menstrual cycle.

In this week's Pearl, we will examine some of these concerns, debunk the myths and provide some clarity (where it exists!) on the veracity of these claims. Click PDF to read our full article.

NICE approves new cholesterol-lowering drug. What are the implications for primary care?

21 Oct 2021

A new drug for the management of hypercholesterolaemia has just been approved by NICE for use in primary care (NICE TA733). We are already being asked about this by our patients. What is this drug, and what should we be telling them?

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NICE approves new cholesterol-lowering drug. What are the implications for primary care?

A new drug for the management of hypercholesterolaemia has just been approved by NICE for use in primary care (NICE TA733). We are already being asked about this by our patients. What is this drug, and what should we be telling them?

Incliseran is a PCSK-9 inhibitor (a what? – don’t worry, we will explain!). NICE says this drug can be used for patients where:

  • There is a history of cardiovascular events:
    • Acute coronary syndrome (such as myocardial infarction or unstable angina needing hospitalisation)
    • Coronary or other arterial revascularisation procedures
    • Coronary heart disease
    • Ischaemic stroke
    • Peripheral arterial disease

AND

  • Low‑density lipoprotein cholesterol (LDL-C) concentrations are persistently 2.6mmol/l or more, despite maximum tolerated lipid‑lowering therapy

AND

  • The company provides the drug according to the commercial arrangement (discount) it has agreed.

 

Click PDF to read our summary of how these drugs work, and how and when they can be prescribed…

The 2021 flu campaign in primary care – our summary of which groups are eligible and which vaccines to use

14 Oct 2021

As we are all aware, there is a big push this year to keep flu vaccine uptake at a high level; the aspiration is to build on what we achieved last year.

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The 2021 flu campaign in primary care – our summary of which groups are eligible and which vaccines to use

As we are all aware, there is a big push this year to keep flu vaccine uptake at a high level; the aspiration is to build on what we achieved last year.

But when you consider that as well as vaccinating the cohort covered last year, there is also expansion in the children’s programme, plus we need to give COVID vaccine boosters too – well, it’s no wonder my brain is feeling a bit fried! Hopefully, our summary article will help ensure your brain stays serene and calm!

Acupuncture for pain: when should we consider it and what is the evidence behind it?

07 Oct 2021

Acupuncture is one of a number of treatment options NICE recommends in its 2021 guidance on the management of chronic pain (NG193), and also in the management of migraine (CG150). What do we need to know about this treatment option and the evidence behind it?

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Acupuncture for pain: when should we consider it and what is the evidence behind it?

Acupuncture is one of a number of treatment options NICE recommends in its 2021 guidance on the management of chronic pain (NG193), and also in the management of migraine (CG150). What do we need to know about this treatment option and the evidence behind it?

Traditional acupuncture is used for a wide number of conditions based on its historical use in China. From this broad base, western medical acupuncture has adopted a narrower focus restricted to medical conditions for which evidence has accumulated over the past 50 years. It is not widely taught in medical training, and might be a gap for those of us working in primary care with patients suffering from chronic pain. What do we need to know about this treatment option and the evidence behind it? Click PDF to read our summary...

Recurrent miscarriage and progestogens

30 Sep 2021

A letter comes from the hospital asking you to prescribe vaginal progestogens to a woman who has conceived but has a history of recurrent miscarriage. What do you do? NICE and RCOG guidance currently does not advise progestogens in early pregnancy for miscarriage prevention.

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Recurrent miscarriage and progestogens

A letter comes from the hospital asking you to prescribe vaginal progestogens to a woman who has conceived but has a history of recurrent miscarriage. What do you do? NICE and RCOG guidance currently does not advise progestogens in early pregnancy for miscarriage prevention.

There is some evidence emerging that vaginal progestogens may be effective in those with recurrent miscarriage (not other groups of women) (the PRISM study, a Cochrane review). In light of the latest evidence, some hospitals ARE recommending it for women with recurrent miscarriage. It is an off-licence preparation for this indication. It may therefore be reasonable to prescribe it, on specialist advice, to a woman with recurrent miscarriage, and, with time, the guidance may change to reflect this latest evidence. The studies used a 400mg vaginal Utrogestan capsule twice daily until 16 weeks gestation. Click PDF to read our full article.

Early cancer diagnosis & testicular cancer

23 Sep 2021

Since the COVID-19 pandemic restrictions started to ease, NHS cancer services have seen record referral levels, but concerns remain about presentations and diagnoses delayed during the pandemic.

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Early cancer diagnosis & testicular cancer

Since the COVID-19 pandemic restrictions started to ease, NHS cancer services have seen record referral levels, but concerns remain about presentations and diagnoses delayed during the pandemic.

This autumn, we are launching our Early Cancer Diagnosis half-day webinar focused squarely on how to improve earlier diagnosis of cancer, while also avoiding some of the common pitfalls which can trip you up along the way.

The need for prompt recognition of possible cancer symptoms is something all clinicians are aware of and ‘sieve for’ as we take a history in our clinic. Of course, we have the NICE 2015 Cancer guidance to turn to when wondering which symptoms should concern us. But a recent study on testicular cancer show us that this is not always the whole picture.

A helpful 2018 primary care study in the BJGP looked at which symptoms should make us concerned about testicular cancer, and not all of them feature in the NICE 2015 cancer guidance referral criteria! (BJGP 2018;68(673):e559).

The study identified nine symptoms that had a statistically significant association with testicular cancer. It then calculated the positive predicative value for these symptoms, and identified ‘clusters’ of symptoms which should prompt investigation. Click PDF to read our summary of this study and find out which symptoms we need to look for...

And for more like this, follow the link to book a place on our Red Whale Cancer Update course this autumn.

Screening for diabetes

16 Sep 2021

Knowing how and when to screen for diabetes is important for us all but can be complex. This week we summarise the latest guidance.

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Screening for diabetes

Knowing how and when to screen for diabetes is important for us all but can be complex. This week we summarise the latest guidance.

It is a busy Wednesday afternoon. You are tackling the backlog of chronic disease monitoring left in the wake of COVID-19, running a remote asthma review clinic. Ana’s asthma is ok, but she mentions she’s had a work medical. Her fasting sugar test was raised. “I thought I should just mention it while I am here…” What do you do next?

> Repeat it?

> HbA1c – she won’t need to fast (bonus), and if she’s got diabetes then we’re halfway there.

> I don’t know… I need more information!

Developing diabetes is often a worry for patients, and knowing how and when to screen is important for us all.

But screening for diabetes is complex, especially when we take risk factors such as ethnicity and co-morbidity into account. In 2017, NICE updated its guidance on when we should be screening for diabetes in primary care (NICE 2017 PHG238). 

  • This work is not just for us in primary care! The guidance also encompasses public health teams, community pharmacists, those working with people with learning disabilities, dentists and prison teams. We can share this task!
  • We should screen certain specific groups:
    • Adults with related comorbidities (CVD, hypertension, obesity, gestational diabetes, PCOS and people with learning disabilities – I’m not sure I always think to check in all of those groups!).
    • Specific ethnicities: South Asian, Chinese, Black African and African Caribbean.
    • Anyone aged >40y, as part of the NHS health check.
       
  • The screening is a two-stage process:
    • Stage 1: assess risk of diabetes in high-risk people. This should be done using a validated scoring tool (NICE doesn’t tell us which one to use!).
    • Stage 2: in those deemed at high risk on the scoring tool, do a blood test (HbA1c or fasting plasma glucose), and offer the appropriate intervention according to the result of the blood test.
    • For people of South Asian and Chinese ethnicity with a BMI >23, the guidance advises we should skip Stage 1 of this process; all this group should be offered a blood test.

So, is screening for, and treating, prediabetes worth it?

The bottom line is that trials have shown that treating prediabetes reduces risk of progression to diabetes. This seems likely to be a good thing, but there is not yet the solid data to show reduced morbidity or mortality.

Click through to read our summary of the 2017 NICE guidance and consider how it might apply to your population.  If type 2 diabetes was on your PDP this year (and let’s be honest – it usually is, as such a significant part of our primary care workload!), you might find our new diabetes half-day webinar (covering drugs, lifestyle, diet and more) a useful place to start.  

Steroid Emergency Cards

09 Sep 2021

In August 2020, a National Patient Safety Alert was issued regarding the use of a Steroid Emergency Card to support early recognition and treatment of adrenal crisis in adults. This week we pull together resources to help you identify who needs a Steroid Emergency Card and how to manage them.

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Steroid Emergency Cards

In August 2020, a National Patient Safety Alert was issued regarding the use of a Steroid Emergency Card to support early recognition and treatment of adrenal crisis in adults. This week we pull together resources to help you identify who needs a Steroid Emergency Card and how to manage them.

We know from feedback on our Red Whale GP Update Together events that many of you, in your surgeries and at PCN level, have been busy running searches to identify those at risk and providing them with a card. Well done, if you have managed to identify your cohort of patients! We also know that there are many of us in primary care who are still working on this project, and we have pulled together a number of resources into one handy PDF. This details what constitutes a significant steroid dose and:

  • Who needs a Steroid Emergency Card.
  • Who needs a Steroid Emergency Card AND advice about how to manage sick days.
  • Who needs a Steroid Emergency Card AND advice about how to manage sick days AND a supply of hydrocortisone to keep at home to administer in case of illness.

 Once we have identified who should have a Steroid Emergency Card, what advice should we give if that person then becomes acutely unwell? And what about if they are acutely unwell with COVID – does that make a difference? We have also summarised the sick day rules for those on long-term steroids for you.

 ALL this information is in this week’s Pearl, as well as links to useful patient information leaflets on sick day rules. Click PDF to read our article.

 If you want to find out more about this topic, we will be covering it on our Autumn/Winter 2021 GP Update course, as well as much more, so do come and join us!

Testosterone and the menopause – when should we consider prescribing?

02 Sep 2021

Women report that they struggle to have their menopause symptoms taken seriously and some believe that being on testosterone will improve their energy levels and mood. So, when should we consider testosterone, and who might it be useful for?

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Testosterone and the menopause – when should we consider prescribing?

Women report that they struggle to have their menopause symptoms taken seriously and some believe that being on testosterone will improve their energy levels and mood. So, when should we consider testosterone, and who might it be useful for?

It is a truth universally acknowledged that a female GP of a certain age will undoubtedly be having many, many conversations about menopause: with patients, with colleagues and with friends – even at the school gates! I am sure my male colleagues are also having these consultations (though possibly less often in the supermarket?!) and that the wider clinical team in primary care is also being asked the same questions. When is the right time to start HRT? Who needs HRT? What is the best way to prescribe HRT?

Women report that they still struggle to have their menopause symptoms taken seriously, and it has never been a hotter topic in the media. Our menopause half-day course will cover all these topics, and also some of the trickier HRT dilemmas such as managing women for whom HRT might increase risks of other conditions, and which non-HRT options are backed by evidence.

I am being asked more and more often about whether a woman needs testosterone alongside her other HRT – and I will admit that it is an area I do not feel confident in at all. Women may believe that being on testosterone will improve their energy levels and mood, or may feel that without testosterone they aren’t being offered the 'full package' of HRT they need.

So, when should we consider testosterone, and who might it be useful for? Click PDF to read our Pearl.

New-onset epilepsy in older people

26 Aug 2021

New-onset epilepsy in older people (>65y) is often treated after just a single seizure. Why is this?

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New-onset epilepsy in older people

New-onset epilepsy in older people (>65y) is often treated after just a single seizure. Why is this?

It can sometimes be a challenge in primary care to juggle the risk of polypharmacy in our frail older patients, and to know when is the right time to be proactive about prescribing vs. when to sit back and adopt a watch-and-wait approach. In our GP Update course back in Autumn last year, we discussed just such a dilemma: the management of new epilepsy in older people.

After a first seizure in young people medication is often only started after a second seizure.

In contrast, new-onset epilepsy in older people (>65y) is often treated after just a single seizure. Why?

  • There is more likely to be an underlying cause – for example, scarring from a stroke.
  • The risk of harms from seizures may be greater – for example, falling triggered by a seizure is much more likely to result in a significant fracture.
  • As people get older, they are increasingly likely to live alone: seizures may be unwitnessed and there is an increased risk of sudden unexpected death in epilepsy (SUDEP).

Clearly, all older people with a seizure need to be seen urgently at the hospital for a full workup (immediately if you think there may have been a stroke that triggered this; 2ww if you are concerned there may be an underlying tumour; and neurology outpatients within 2 weeks for all with new onset of seizures). The decision to treat is made by the hospital but we will often be left to up-titrate the medication. Bear in mind that as a general rule of thumb, the initial dose and rate of titration of antiepileptic medication in older people should be about half of that in younger patients; this helps with tolerability.

If this feels like the sort of useful information no one else is teaching you, maybe now is the time to join our upcoming GP Update Together course on Wed 8 Sept. Lots of relevant and challenging primary care topics, and all in our usual interactive and memorable Red Whale style, delivered to your laptop. All the benefits of a Red Whale course, plus the bonus of your own coffee, just how you like it!

 

Capacity and consent – what is the role of primary care?

19 Aug 2021

How do we satisfy ourselves that we have done all we can to support a patient to have capacity in any given decision? And how do we tell if someone can understand and retain enough information to make a valid decision?

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Capacity and consent – what is the role of primary care?

How do we satisfy ourselves that we have done all we can to support a patient to have capacity in any given decision? And how do we tell if someone can understand and retain enough information to make a valid decision?

One question that came up repeatedly on our recent Older People and Frailty Together course was how much clinicians in primary care should be involved in decisions about capacity, and how to assess capacity when needed.

At any one time, it is estimated that 2 million people in England and Wales may lack the capacity to make decisions around their healthcare provision. The Mental Capacity Act 2005 (England/Wales) and the Adults with Incapacity Act 2000 (Scotland) were put in place to provide a framework to support adults who lack capacity to make decisions for themselves. In 2018, NICE released guidance on how to apply the MCA in practice (NG108).

As clinicians, we need to be able to assess whether our patient has capacity to consent to, or decline, the treatment we are suggesting for them. GPs are not obliged in the GMS contract to assess capacity for anything other than patient care.

NICE outlines our responsibility to support people in making decisions about their care by:

  • Providing appropriate, tailored and accessible information about the decision to be made, and adequate time to make the decision.
  • Using tools to support this decision-making process where needed.
  • Ensuring a person has an independent mental capacity advocate (IMCA) if appropriate.
  • Offering information and advice on advance care planning where appropriate.

However, all of this is easier said than done. How do we satisfy ourselves that we have done all we can to support a patient to have capacity in any given decision? And how do we tell if someone can understand and retain enough information to make a valid decision?

Our article on capacity and consent outlines a useful guide on how to perform these assessments, and if the care of older or frail people is on your PDP this year you might like to register for our on demand version of this half-day course, where we cover this topic and much more! Find out more to about our Older people and frailty webinar!

Pelvic floor exercises and prolapse

12 Aug 2021

In women with a prolapse, pelvic floor exercises really do work! A trial of women who did pelvic floor exercises for all types of gynaecological prolapse (anterior, posterior, vault/uterine descent or a combination of these) found that, after 4 months, the NNT was 3 to improve the prolapse. Watch Lucy Cox's video on pelvic floor exercises.

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Pelvic floor exercises and prolapse

In women with a prolapse, pelvic floor exercises really do work! A trial of women who did pelvic floor exercises for all types of gynaecological prolapse (anterior, posterior, vault/uterine descent or a combination of these) found that, after 4 months, the NNT was 3 to improve the prolapse. Watch Lucy Cox's video on pelvic floor exercises.

Women also reported better bladder and bowel function, and sex life. So, what exercises to recommend? In this trial, women were asked to do 50 quick contractions and 10 × 10sec holds three times a day for 4m. They were supervised by a physio for the trial, but I suspect most of us won’t have that luxury in our practice! Worth a try? Click PDF to read our article.

Self-harm in teens

05 Aug 2021

Self-harm in teens – can we predict who is most at risk? And what should we do when we see it?

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Self-harm in teens

Self-harm in teens – can we predict who is most at risk? And what should we do when we see it?

Managing adolescent mental health problems is often one of the more difficult things we do in primary care. Despite improved awareness of teen mental health problems, young people still find it difficult to reach out before they hit crisis point. If they do reach out, it is crucial that the health professional they approach is compassionate and open minded.

  • 10% of girls and 3% of boys aged 15–16y have self-harmed in the previous year.
  • Self-harm increases the likelihood that someone will die by suicide by 50–100-fold over a 12m period.
  • Almost 50% who die by suicide have seen their GP in the preceding month (BJGP 2016;66;e737).

So, how can we spot these kids, and what can we do to help them when we do?

A team working at the University of Cambridge recently identified some common patterns in children presenting with self-harm. They found that some of the warning signs for this behaviour might appear up to a decade earlier, which might help spot those most at risk. There were 2 groups identified. The first group showed a long history of poor mental health, and the second group (a much larger number of individuals) showed impulsive behaviour and a greater tendency to risk-take. These children rated relationships with their peers highly, and might be less able to cope with difficulties in their peer group than others.

Teenagers at greatest risk of self-harming could be identified almost a decade earlier | University of Cambridge

Click PDF for our summary of the assessment and management of self-harm in primary care.

Chloramphenicol eye drops in little people: can you or can’t you?

29 Jul 2021

A few weeks ago, we released a Pearl on the management of conjunctivitis with chloramphenicol for children <2y. We told you that, most chloramphenicol drops had added a contraindication for children under 2 years of age. But the MHRA has now issued guidance saying we can use them. Watch Nik's video for more.

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Chloramphenicol eye drops in little people: can you or can’t you?

A few weeks ago, we released a Pearl on the management of conjunctivitis with chloramphenicol for children <2y. We told you that, most chloramphenicol drops had added a contraindication for children under 2 years of age. But the MHRA has now issued guidance saying we can use them. Watch Nik's video for more.

We previously told you that, subsequent to European Medicines Agency advice on exposure to boron-containing medicines, most chloramphenicol drops had added a contraindication for children under 2 years of age. But the MHRA has now issued updated guidance.

Here is its advice:

Following a review of the available toxicological data and a calculation of daily exposure to boron from a typical dosing regimen, we have concluded that the balance between the benefits and risks of chloramphenicol eye drops containing borax or boric acid remains positive for children aged 0 to 2 years. Chloramphenicol eye drops can be safely administered to children aged 0 to 2 years where antibiotic eye drop treatment is indicated.

Here is a link to the MHRA guidance.

This is welcome news, but remember, most people don’t benefit from antibiotic drops anyway. If you would like a reminder on the management of conjunctivitis, click PDF to read our updated Pearl.

Heatstroke GEMS

22 Jul 2021

Public Health England releases alert warning of risks to health from soaring temperatures this week! What should we do to help patients who present with heatstroke?

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Heatstroke GEMS

Public Health England releases alert warning of risks to health from soaring temperatures this week! What should we do to help patients who present with heatstroke?

This week has seen record-breaking temperatures in some parts of the UK. Public Health England and the Met Office have both issued warnings that the very high temperatures could put the vulnerable at risk of heatstroke. They advise staying out of the sun between 11 and 3, drinking plenty of fluids and avoiding exercise in the hottest parts of the day.

Our oldest and youngest patients are at greatest risk of heatstroke, as well as those who need to exert themselves in high heat due to their work (farm workers, firefighters and athletes, for example).

The body’s metabolic rate rises and compensatory mechanisms are overwhelmed, leading to a rapid rise in core temperature and triggering symptoms such as nausea, dizziness and confusion.

So, what should we do to help patients who present with heatstroke? Click through for our handy 1-page GEMS on this topic, then relax in the shade with a cool drink while you read it!

Painful coil insertions – what can we do to avoid them?

15 Jul 2021

Women experiencing painful coil insertions have been heard! The FSRH issued updated guidance at the start of July 2021 on how to help our patients. 

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Painful coil insertions – what can we do to avoid them?

Women experiencing painful coil insertions have been heard! The FSRH issued updated guidance at the start of July 2021 on how to help our patients. 

There has been a fair amount of media interest recently in the fact that for some women, the fitting of an IUC is painful, and that many women are not aware what pain relief options could be available to them. IUC fitting is only mildly uncomfortable for most women; however, some will find it significantly painful. The FSRH issued updated guidance at the start of July 2021 which recommends that:

“Healthcare professionals should create a reassuring, supportive environment, offer appropriate analgesia (and referral on to another provider if they cannot offer this…”

So, what can we do to help?

A 2015 Cochrane review looked at this question and found a few surprises!

Do you advise women to taken ibuprofen pre-med? It won’t help with pain during the fitting, though may help with post-insertion cramps, so we can still recommend it. How about instillagel? Nope, that doesn’t work either! Naproxen or tramadol may be helpful, and of course local anaesthesia is a great option – but which is the best route?

This week, we are sharing an article all about fitting techniques for IUC insertion, including advice on which methods reduce pain, and how to use them. Together, let’s work so that fewer women experience pain in managing their contraception. Click PDF to read our article.

How to spot migraine in kids

08 Jul 2021

How do we diagnose abdominal migraine in children? What are the red flags we need to rule out first? And once we've made the diagnosis, what do we do next?

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How to spot migraine in kids

How do we diagnose abdominal migraine in children? What are the red flags we need to rule out first? And once we've made the diagnosis, what do we do next?

My patient was 7 and came in with her Dad, who was clearly worried. They described episodes of severe abdominal pain off and on for over a year, sometimes with a headache but not always, and often with a stiff neck and nausea. In between, she was totally well. Over the months, they had had bloods (normal), examinations (also normal) and urine tests (clear), and GPs had sought the advice of paediatricians. I looked at her swinging her legs in my too tall surgery chair, and tried to remember what the criteria were to diagnose abdominal migraine, and what I needed to do next – so I looked it up on my Red Whale online handbook, without which I could not get through most days at work! A 2018 BMJ clinical update encouraged us to make a positive diagnosis of abdominal migraine once we have ruled out red flags. When thinking about red flags, we need to remember coeliac disease, diabetes, recurrent UTI and inflammatory bowel disease, among other things. Click through to our full article to find out more.

Chronic Pain: communication skills and self-management

01 Jul 2021

This week we're looking at practical tips, tools and ideas to help support people with chronic pain. Take a look at our Pearl article and sign up for our FREE webinar in association with Versus Arthritis where we explore these issues further.

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Chronic Pain: communication skills and self-management

This week we're looking at practical tips, tools and ideas to help support people with chronic pain. Take a look at our Pearl article and sign up for our FREE webinar in association with Versus Arthritis where we explore these issues further.

This article focuses on:

  • Why excellent communication is essential and how we can change the conversation.
  • How to create a shared understanding of chronic pain, and why this helps!
  • Supporting people with self-management.
  • Ideas for creating personalised care plans with people living with chronic pain.

Click PDF to read the Red Whale article on Chronic pain: communication skills and self-management.

We have teamed up with Versus Arthritis to offer you the opportunity to explore these issues further in a FREE webinar. Join Dr Giles Hazan (GPwER in Chronic Pain) and Dr Benjamin Ellis (Consultant Rheumatologist who sat on the NICE committee that wrote this guideline) ON DEMAND from the Red Whale sofa from Wednesday 7 July to look at these skills and lots of hints and tips that you can put into practice straight away.

Sign up for one or both of our FREE chronic pain webinars, in association with Versus Arthritis.

And we can only do this as a team, so please, share this with any clinical members of your primary care team who you think might be interested – everyone is welcome!

Venous thromboembolism after COVID 19 vaccination

24 Jun 2021

As we go into the final push to get the adult population vaccinated for the first time, we wanted to share with you an update on the link between venous thromboembolism and COVID-19 vaccination. Data continues to emerge.

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Venous thromboembolism after COVID 19 vaccination

As we go into the final push to get the adult population vaccinated for the first time, we wanted to share with you an update on the link between venous thromboembolism and COVID-19 vaccination. Data continues to emerge.

It’s busy. Primary care is battling on (at least) 3 fronts at the moment: pent-up demand, delivering the biggest vaccination campaign EVER and possible side-effects from vaccination! 

The key message is that we should be considering thromboembolism with thrombocytopenia if ANY of the following occur 4–28d after COVID-19 vaccination: 

  • Headache that is:
    • New, worsening and not responding to simple analgesia.
    • Worse when lying down/bending forwards or associated with nausea/vomiting, blurred vision, drowsiness or seizures (symptoms that may indicate raised intracranial pressure).
    • Associated with speech disturbance or weakness (symptoms of focal neurology).
  • New, unexplained pinprick bruising or bleeding.
  • Shortness of breath, chest pain, leg swelling.
  • Persistent abdominal pain or signs of thrombosis at other sites.

But how should we assess people? Who needs referral? How should we report suspected cases? 

This week’s Pearl shares the evidence and guidance as it stands at present.

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.

More info PDF

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.

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?

More info PDF

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.

More info PDF

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!

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