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Latest Updates - 'Pearls' from the Red Whale

Our updates are ideal for bite-sized CPD and study group discussions!

"Great to see inclusions of bits for locums"

Supporting you throughout your CPD journey - one update at a time

Our regular updates or ‘Pearls’ are topical items relating to primary care. Each one is drawn from the latest research, clinically relevant to issues in general practice, and linked to an article in our handbook.

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Red Whale Pearls are copyright free so you can print off as many hard copies as you like and forward soft copies to your colleagues to your heart's content. All we ask is that you acknowledge us as the source.

Calling all locums and would-be locums to our Locum Essentials Guide.

Find our specialised Pearls for Primary Care Nurses here.

Hypertension - diagnostic thresholds: are you using the correct ones?

23 May 2017

Hypertension - diagnostic thresholds: are you using the correct ones? A recent survey showed that more than half of GPs in 2015 were using the wrong thresholds to make the diagnosis!
In clinic, if the BP is ≥140/90, you should do ambulatory monitoring. If the ambulatory BP is ≥135/85, diagnose hypertension. Home monitoring is an alternative if ambulatory is not tolerated. For home readings, the diagnostic threshold is also ≥135/85: you do NOT adjust by 10/5. Clinic readings are not recommended for diagnosis.

Looking after yourself

17 May 2017

It seems that the pressure in primary care is mounting. With the cyberattack this week causing disrupted surgeries, and extra paperwork on top of the increasing pressures on the NHS, it can feel like the gods are conspiring against us. In times like these, it’s important to look after your biggest asset – that’s you, by the way!
On our Lead. Manage. Thrive! course, we frequently ask delegates to write down the first thing they stop doing when they are too busy or stressed. We then ask them how important that thing is for their mental health and wellbeing. Guess what? When we’re too busy and stressed, the first thing we drop from our lives is often the ONE THING THAT IS HUGELY IMPORTANT to keep us re-energised, well and mentally fit. This could be exercise, meeting up with a friend, connecting with a partner, doing yoga or meditation, reading a book, climbing a mountain………the list goes on.

Nausea and vomiting in palliative care. One chance to get it right.

10 May 2017

The gap left by the withdrawal of the Liverpool Care Pathway was filled in 2014 by a joint statement by interested parties called ‘One chance to get it right’. This stated that end of life care should be delivered around five pillars, one of which is individual care plans. Symptom control is an essential part of an individual care plan. Nausea and vomiting are often present in a palliative care context, and managing these symptoms effectively can make all the difference for a patient.

Quick-starting and bridging

02 May 2017

Teenage pregnancy rates have declined dramatically. There is debate about the reasons for this decline in what is being called ‘Generation Sensible’. Whatever the contribution contraception might be making to this decline (in particular LARCs), there is an important place for quick-starting and bridging for women, whether teenagers or older.

Evidence is emerging of risks with long-term use of PPIs, and the list is long!

26 Apr 2017

• Increased risk of:
- Clostridium difficile.
- Hospital acquired pneumonia.
• Association with:
- Increased risk of hip fractures in women.
- Dementia in older people.
- CKD.
- Low serum magnesium levels (leading to recommendations to check magnesium levels in those with symptoms and those also on other high-risk drugs, e.g. digoxin and diuretics). Symptoms of low magnesium are rare but often insidious (fatigue, dizziness), although they may be more serious (tetany, delirium, convulsions, ventricular arrhythmias).
• Possible associations with:
- Increased risk of MI.
- Community acquired pneumonia.

Neutropenic sepsis: NICE guidance

19 Apr 2017

A very serious complication that has the simplest guidance for GPs.
Neutropenic sepsis is a potentially fatal complication of chemotherapy treatment. The mortality rate has improved with rapid administration of antibiotics.

Managing stress

11 Apr 2017

Yes, we know the symptoms of stress, and stress management is something we discuss with our patients all the time. Yes, we know that stress and performance are related – for us, as well as our patients. But do we recognise it when it is happening within ourselves? Doctors are prone to stress and burnout, and we are not always good at recognising and acting on it.

Research published in 2016 by the King’s Fund showed that increasing workloads are the biggest source of stress for GPs. In our recent Red Whale survey of GPs, increasingly unmanageable workloads were described by 85% of the approximately 1,000 respondents as the single most negative aspect of their careers. The good news is that we CAN learn to manage stress. It CAN be different.

Miscarriage: frequently asked questions

04 Apr 2017

Miscarriage can be a devastating event. The hopes and dreams associated with a new pregnancy suddenly dashed. Women do not necessarily have contact with primary care at the time of miscarriage, and are often left with many unanswered questions. Some are unanswerable. These questions are likely to include: Why? Why me? What did I do wrong? What can I do to prevent a miscarriage if I try again? How soon should I try again? So, how can we best answer these questions, and what can we say about reduction of risk?

Is this bipolar?

28 Mar 2017

You have been treating Jim for depression but he seems now to be a little ‘high’. He has thrown in a good job and you recall that he has done this precipitously with previous employments. 

NSAID's: effectiveness and safety

22 Mar 2017

NSAIDs are often prescribed as part of the management of chronic pain, and this may be appropriate. However, NSAIDs have risks, and their benefits in chronic back pain and osteoarthritis are marginal. Diclofenac and high-dose ibuprofen are now contraindicated in patients with established IHD, peripheral arterial disease, cerebrovascular disease and congestive heart failure.

What, then, are the alternatives? When should we co-prescribe a PPI?

Click below to see our summary of a BMJ review looking at the effectiveness and safety of NSAIDs.

Should lesbian and bisexual women have a smear?

16 Mar 2017

And, while we are looking at medical topics making the news, another Pearl that we sent out in 2015 warrants a reminder. The BBC, as well as the Telegraph and the Sun, have picked up on the LGBT Partnership focus for National LB Women’s Health Week. This highlights the low levels of uptake for cervical smear tests among lesbian and bisexual women, and the issue of misinformation about the need for cervical smears.
Should lesbian and bisexual women have a smear?

Sepsis - a reminder

15 Mar 2017

“The family GP said he just needed Calpol, but Patrick's mother was still concerned and took him to hospital.” This is from a BBC article “The biggest killer you may not know” written to raise awareness of sepsis. 
The article and the comments that follow it on the BBC website show how challenging it can be to make the diagnosis of sepsis, and how devastating it can be if it is missed or the diagnosis is delayed. One of the comments poignantly says “I hope the GP was made aware of his huge mistake so he/she could learn from it”.
We sent out a Pearl on the new NICE sepsis guidelines in July 2016 when they were released. However, with this publicity raising patient awareness, a reminder about the sepsis guidelines is timely.

Introducing our new 'Locum Essentials Guide'

08 Mar 2017

Are you a locum? Are you about to become a locum? Perhaps you are thinking about this as a career option, either short or long term? We know many of you are locums or are entertaining the idea of becoming locums, perhaps after a salaried career or a baby, or even after training.
This can be a scary move. You have to think about the financial aspects: invoicing, pension, tax, expenses. Then there are the challenges of clinical management, and the difficulties in meeting all the requirements for revalidation when you are not practice based. We may have just what you need!

So, how will you manage Joan's hoarse voice?

01 Mar 2017

Joan, now age 48y, tells you that she has been teaching for many years so using her voice is just part of the job. She is, however, finding teaching increasingly stressful, and admits that she does still smoke cigarettes which help her to relax at the end of a busy day. She was not particularly concerned about the change in her voice some five weeks ago, thinking it would eventually settle.

However, several colleagues have now commented on the hoarseness, and it did not improve over the half-term break. She has not had a cough or a cold. She is not otherwise unwell. Examination of her throat, neck and chest is unremarkable.

Diagnosing menopause

22 Feb 2017

Hot flushes, night sweats, menstrual irregularities and vaginal dryness. These symptoms are common in the perimenopausal period, and can have a significant impact on a woman's life. In 2015, NICE produced its first guidance on the diagnosis and management of menopause, seeking to clarify the balance of benefits and risks of HRT, as well as other menopausal treatments.

So, what about diagnosis? It is retrospective - defined as >1y amenorrhoea if age >50y, or >2y amenorrhoea if age >45y. And for women>45y, the diagnosis is clinical. FSH testing should be reserved for diagnosing premature ovarian failure and in deciding whether to stop contraception.

Latest alternative truth on breast cancer prevention - setting the record straight

17 Feb 2017

“Ignorant GPs deny patients drugs that ward off cancer.”  
Headline from the Daily Mail on 14th February 2017.

Oh, joy – big sigh (correction, overwhelming fury!) from this Red Whale author. This article was written in response to a qualitative study published in the BJGP relating to using tamoxifen and raloxifene to prevent breast cancer. 

It represented a wholly inaccurate reflection of the current situation in England – post-truth news!

So we had to set the record straight and you get an extra pearl this week.

Do you delegate effectively?

15 Feb 2017

Delegation is something we all do. It is about entrusting others with a task, while maintaining responsibility. It is a core personal skill. We might or might not feel comfortable delegating tasks, and we might or might not delegate well. How is our delegation perceived by others in our teams? As dumping? Inappropriate? Exploiting our authority?

What are the treatment options for premature ejaculation?

08 Feb 2017

Tony has probably taken some time to pluck up the courage to come and talk about this most intimate of problems. His struggle with premature ejaculation is affecting his self-esteem and sense of manhood. He is convinced that his partner is dissatisfied, although he admits he has not felt able to discuss his concerns with her and does not know what she truly feels. 

Assisting patients prompted by 'Time to Talk Day' 2017

01 Feb 2017

Thursday 2nd February is ‘Time to Talk Day 2017’. This is a wonderful initiative that will get many people talking about mental health.

How well prepared are you for conversations patients might wish to have with you, having been prompted by Time to Talk Day?

‘Time to Change’ is led by Mind and Rethink Mental Illness. It describes itself as a movement which aims “to transform how we all think and act about mental health problems”. It notes that the attitudes of others (including, sadly, health professionals) can stop people with mental health problems getting the help and support they need, and says that “too many people with mental health problems are made to feel isolated, ashamed and worthless”

Second malignancies in the survivors of cancer

25 Jan 2017

One of the most life-threatening sequelae of cancer and its treatment is the diagnosis of a second cancer!

Second cancers occur for several reasons, including shared environmental aetiological factors (notably smoking, alcohol and obesity), genetic factors, and late effects of cancer treatments.

It is becoming increasingly apparent that some individuals are more genetically susceptible to treatment-related risks than others. 

PCOS, fertility and pregnancy. What are the risks, and does metformin help?

18 Jan 2017

We know that PCOS increases the risk of fertility issues due to chronic anovulation. If a woman does fall pregnant, PCOS significantly increases the risk of adverse obstetric outcomes including gestational diabetes, pre-eclampsia and preterm birth.

Informing patients about total knee joint replacement

11 Jan 2017

Jane, at age 72, is still fit and enjoys playing golf regularly. She has osteoarthritis in both knees, but the right knee is now more troublesome when she is walking and this is starting to affect her golf. Sometimes she can only manage a couple of holes because of knee pain. She is very keen to have a new knee.

Appraisal and revalidation: RCGP guidelines 2016

05 Jan 2017

2017! A new year. Time for reflection and resolutions. If you have thought about resolutions for 2017 these might have included thoughts about appraisal. If you are like us, one of your resolutions might be to keep on top of your planned PDP as the year proceeds. Reflecting and writing up as we go along rather than a last minute scramble before the appraisal date looms on the horizon.

Perhaps your resolutions relate to completing that learning activity on your PDP, doing an audit, reflecting on a case review or a significant event in a more structured way that will actually have an impact on your practice.

Assertiveness: win friends and influence people!

15 Dec 2016

Your colleague, James, has put in a request for annual leave. As usual, he seems to have given no thought to what his absence will mean for the practice and for you in particular.

It is your day as duty doctor. You will be left without cover for the scheduled visit to the local nursing home. Last time, not wanting to be difficult about the request, you agreed. You had an awful day, stressed to the max, and struggled to manage the demand. You felt so angry and taken for granted, but you were unable to express any of this.

How do you respond to James this time without either folding like a wet blanket or exploding with anger?

Testicular cancer treatment – a real success story

07 Dec 2016

50 years ago, 90% of patients presenting with metastatic testicular cancer could expect to die within 12 months. Now, 95% of patients receiving a diagnosis of testicular cancer can expect to be cured, as can 80% of those who present with metastatic disease.


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