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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.

Women aged 35–44y with systemic lupus erythematosus (SLE) are fifty times more likely to suffer an MI compared with age-matched controls

11 Oct 2017

SLE is a rare and complex condition. 

•    In the first 5 years after diagnosis, disease activity and infections are the commonest cause of morbidity and mortality. 
•    Thrombosis is the commonest cause of death over the next 5 years. 
•    The overall mortality rate in the first 10 years is 8%!
•    In one study, over one-quarter of patients with SLE were found to be depressed. Dissatisfaction with support, a poor understanding of the disease, and unsatisfactory contacts with medical staff were all cited as contributing to this. 

Is CRP point-of-care testing helpful in deciding which patients with LRTI need antibiotics?

04 Oct 2017

NICE recommends:
•    Offer point-of-care CRP tests ONLY in non-pneumonia LRTI where there is uncertainty about prescribing antibiotics. 
•    CRP tests should NOT be used in pneumonia – all these patients should be prescribed antibiotics.

However, some words of caution. Although trials of reliability have shown point-of-care tests to be as good as laboratory CRP tests, and some trials have shown reduced use of antibiotics with point-of-care testing, not all trials are positive, and many clinical trials have been funded by the manufacturers.

The second edition of our Locums Essentials Guide

26 Sep 2017

Our Locum Essentials Guide was so well received that we have published a second edition, which includes new material on Administrative Essentials, as well as important Surgery Essentials.

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, especially managing medical emergencies in a context that might be unfamiliar to you. Our guide may be just what you need! 

“How people die remains in the memory of those who live on.” Cicely Saunders

20 Sep 2017

Agitation, restlessness and delirium are distressing to those around them. Research shows this distress can be reduced if you can educate families about it BEFORE it occurs. It is important to remember that ‘normal’ features of dying may be interpreted as agitation/distress by family and carers, for example Cheyne–Stokes breathing and tracheal secretions. 

When it comes to delirium, the key is recognising it. Then, think about the cause. In terminal care, liver failure, renal failure, hypoxia, infection and hypercalcaemia are among the commonest causes.

How often do you diagnose 'genitourinary syndrome of menopause’? Erm…what, I hear you say?

12 Sep 2017

This is the new name for vulvovaginal atrophy, a common and easily treatable condition. Yet only 10% of women who would benefit from treatment actually receive it! 

A Cochrane review suggests that one of the reasons it is underdiagnosed is that we don’t ask specifically about urogenital symptoms.

•    Genitourinary syndrome of menopause (GSM) can affect up to 50% of women.
•    It tends to become apparent 4–5y after the menopause.  
•    Unlike vasomotor symptoms, it does not resolve spontaneously and may become chronic and progressive. 

Difficult conversations: how to have them

05 Sep 2017

In August, we sent an email about ‘difficult conversations’ with colleagues or friends.

We spend our whole day having difficult conversations with patients. We know how to break bad news, give advice that someone doesn’t appreciate, or talk about intimate and embarrassing things without a hint of awkwardness.

But, in reality, most of us find it hard to have a difficult conversation with a friend or colleague in which 'the truth is out there'. Having those difficult conversations is crucial to our wellbeing, and that of our practice, our staff, and ultimately our patients.

Whatever the issue in the conversation you need to have, or have been avoiding, if our previous email got you thinking, you might want to read on.

Helicobacter pylori eradication

30 Aug 2017

Advice to take 3 medications all at the same time to treat H. pylori infection may surprise or worry patients. But eradicating H. pylori has just become even more complicated! Due to concerns about growing H. pylori antibiotic resistance, we should take into consideration previous antibiotics prescribed to the patient.

NICE acknowledges that it is often difficult to establish a person’s previous antibiotic exposure, but, where possible, previous courses of clarithromycin, quinolones and metronidazole should be taken into account in decisions about treatment.

Healthy diet

23 Aug 2017

We regularly advise patients to lose weight or to eat a healthy diet. But when it comes to explaining exactly what this means, we may flounder. Many patients feel bewildered by dietary advice that seems to change from year to year, or find it difficult to translate into real-life choices. What does '30g of fibre per day' mean? And '<30g saturated fat'? The 'Eat Well Guide' was launched by Public Health England in 2016 to update the dietary recommendations in the 'Eat Well Plate'.

HIV. To whom should we be offering tests? When should we offer repeat testing?

16 Aug 2017

The prevalence of HIV infection in England is 1.9/1000 people over the age of 15y. It is estimated that 17% of people living with HIV do not know their status. These rates are higher outside London, with nearly a quarter undiagnosed. HIV testing is critical to providing effective treatment, and preventing disease progression and mortality. Effective treatment also reduces viral load so preventing onward transmission.

Valproate and pregnancy just do not go together!

08 Aug 2017

Taking valproate during pregnancy is associated with a 30–40% risk of serious developmental disorders, and 10% risk of congenital malformations. It should not be used in girls or women of childbearing age (including teenagers), unless other treatments are ineffective or not tolerated.

In 2016, the MHRA strengthened its warnings about the risks of taking valproate medications ​​​​​​during pregnancy. This advise was updated and reissued in 2017 following a survey showing that 20% of women taking valproate were not aware of any of the risks of valproate in pregnancy. It has the following action points for primary care:

Could this be occupational asthma? Think about it in new onset asthma in an adult, or re-emergence of asthma in a patient who had ‘grown out of it’.

30 Jul 2017

About 1 in 10 people presenting like this will have occupational asthma. There are a number of high-risk occupations. Four times daily serial peak flows aid diagnosis, showing a dip on starting work and improvements when away from the workplace. Early referral to a chest physician/occupational physician is recommended. So, are you thinking to ask whether symptoms improve when away from work, or deteriorate when at work?

Click below to see our summary of occupational asthma.

Renal colic and alpha blockers: another twist in the tale!

25 Jul 2017

Previously, we highlighted a meta-analysis showing that alpha blockers aided stone expulsion, and sent you a Pearl all about it, as this seemed a great, easy treatment. Then a UK trial showed this was not the case, and we suggested you stopped using them. However, the latest meta-analysis suggests alpha-blockers do indeed aid stone expulsion, and reduce pain and hospital admission.
So, for patients with renal colic, we should again consider prescribing tamsulosin.
Click below to see our summary of this meta-analysis and management of renal colic.

Tamoxifen with fluoxetine, paroxetine or duloxetine – again!

18 Jul 2017

Yes, we know we are always banging on about this. We highlight the issue again because a multi-database cohort study published in the BMJ in 2016 showed no increased risk of breast cancer in people on tamoxifen and either paroxetine and fluoxetine. This sounds reassuring BUT the median follow-up was only 2.2 years! 

How should we assess and manage terminally ill patients with low mood?

13 Jul 2017

It is normal to feel sad and to undergo adjustment difficulties in the context of a terminal illness. However, clinical depression can also occur in this context. Relieving true clinical depression in terminal illness can help patients and their families to experience a good death.

Women who have had gestational diabetes need follow-up for the rest of their lives

05 Jul 2017

We have previously highlighted that NICE changed its diagnostic criteria for gestational diabetes. But how are we doing with follow-up? After delivery, women who have had gestational diabetes need a fasting plasma glucose at 6–13w (NICE specifically says NOT an OGGT!). If, somehow, this doesn’t happen, after 13w an HbA1c can be done (not sooner, because anaemia/blood loss at delivery may make it inaccurate). These women also need screening for diabetes ANNUALLY for the rest of their lives!

Aspirin and PPIs: more on this drug dilemma

28 Jun 2017

Two weeks ago, we sent out a Pearl on the harms of aspirin and mitigating these, particularly in those over 75, with PPIs. We have received a lot of questions about this, given the Pearl we sent in April focused on the risks of long-term PPIs. How do we balance these risks for any individual patient?
There are clear benefits with aspirin for secondary prevention of CVD, but also potential harms, some of which can be mitigated with PPIs. But, PPIs may affect the efficacy of aspirin, and have potential risks themselves.

Grapefruit juice does increase statin levels. But does it matter?

21 Jun 2017

For simvastatin, 1 glass of grapefruit juice can increase levels by up to 260%. Overall, some researchers have estimated this might actually have some cardiovascular benefits! It probably does not increase the risk of rhabdomyolysis, which is very rare.
Nevertheless, the MHRA still advises that grapefruit juice is avoided when taking simvastatin and atorvastatin.
Click below to see our summary of a trial reported in the DTB in 2016.

Aspirin harms: the latest research in context

14 Jun 2017

So low-dose aspirin is in the news again…this time it is all about the harms, particularly the harms as you get older.

It is also about how the increased risks can be mitigated through PPI use. Do you routinely give PPIs to those over 75y on aspirin? This study suggests you should.

So here is a summary of the latest research, set in the context of what we know already.

I hope you find this useful on a day of grim news from London.

Bone metastases

07 Jun 2017

Ted, at 89 years old, lives independently. Though still quite active, he admits he is starting to feel his age in a way he never has before. His prostate cancer, diagnosed 3 years ago, has not held him back. However, despite treatment, his PSA has started to rise. It is the relatively new, gnawing, aching, pain in his left hip that is making him feel old. Does Ted have a bony metastasis?

Breast, lung and prostate cancers account for 80% of all bony metastases. The main problems caused by bony metastases are pain, pathological fractures, spinal cord compression (an oncological emergency) and nerve root compression. Investigations involve bloods and a variety of radiological tests, though interpreting these may not be straight forward. ALP and calcium can be normal.

Drug interactions with contraception

30 May 2017

With wider uses of existing drugs (e.g. anti-epileptics for migraine and neuropathic pain) and new drugs on the market (e.g. HIV treatments), we need to be aware of any interactions with contraception. Enzyme-inducing drugs can impact on contraceptive efficacy. Numerous HIV medications, along with carbamazepine, phenytoin and other drugs, are strong enzyme-inducers.
Topiramate (now first line for migraine prevention) and St John’s wort (which patients may be purchasing over the counter) are included among the moderate/weak enzyme-inducers.

No additional precautions are necessary when prescribing antibiotics to women using combined hormonal contraception, except for enzyme-inducing antibiotics such as rifampicin/rifabutin.

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.

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