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Latest Updates - 'Pearls' from the Red Whale

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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.

Find our specialised Pearls for Primary Care Nurses here.

Pancreatic cancer

14 Feb 2019

Barry retired 2 months ago, having recently turned 63. He prepared well for retirement, and has started working with a number of organisations he wishes to support in a voluntary capacity. Barry readily says that being able to spend more time with his grandchildren is what he has been most looking forward to in retirement. He had not felt unwell, though retrospectively realises that he had lost some weight. So, when he rapidly developed painless jaundice, it was a huge shock to discover that he has pancreatic cancer. His life, hopes and plans have been turned upside down.

Hypoactive delirium

06 Feb 2019

Mrs Jones, cherished and well cared for by her equally elderly husband, couldn't possibly have delirium as she is not agitated. For some days, however she has fluctuated from seeming to be her usual self to being quiet, withdrawn and sleepy. She "just does not seem to be there" at these times.

There are three subtypes of delirium:

       *  Hyperactive delirium is most commonly recognised and is associated with restlessness and agitation.

       *  Hypoactive delirium accounts for up to 50% of delirium and is characterised by being withdrawn, quiet and sleepy. IT IS EASY TO MISS!

       *  Mixed delirium - exhibits features of both hyperactive and hypoactive delirium.

Mild cognitive disorder – what’s that?

30 Jan 2019

Some people referred into memory clinics will come back with a diagnosis of mild cognitive disorder. What does this mean?

Mild cognitive disorder is cognitive impairment WITHOUT functional impairment. This is in contrast to dementia where there is cognitive impairment WITH functional impairment.

Mild cognitive impairment affects up to 20% of those over 65y. It is a risk factor for dementia, with 20–40% of those with mild cognitive disorder progressing to dementia over the next 3–10 years (compared with only 3% progression in those without any cognitive impairment). Having diabetes/prediabetes, metabolic syndrome or a low folate increases this risk.

Abnormal LFTs

23 Jan 2019

I am sure the scenario will be very familiar to you: mildly abnormal LFTs in a well person with no jaundice.

Does this person have known or suspected risky alcohol intake? Could it be a drug side-effect? Do they have risk factors for viral hepatitis? Could this be autoimmune hepatitis, or might it be non-alcoholic fatty liver disease?

How should we approach teasing this out?

DMARD safety

16 Jan 2019

Another evening, another batch of results from the lab. Mr Rahim’s blood results have several abnormalities highlighted. He has been on a DMARD for years and has had no significant changes with his regular monitoring tests until today. What do you do?

Though DMARDS are initiated in secondary care an require monitoring, shared care is increasingly the norm. There are three types, all with different risks, but ALL have increased risk of infection.

Gynaecomastia: working out the cause

09 Jan 2019

Pete looked shocked when I asked whether he might be using cannabis. “Can that cause me to grow these boobs?”, he asked incredulously. In men, excessive breast tissue has two possible causes:

1) Gynaecomastia: proliferation of glandular tissue, usually firm, sub-areolar swelling – due to hormonal changes.

2) Pseudogynaecomastia: proliferation of adipose tissue – due to obesity.

They can occur simultaneously. Clinically, it can be hard to tell which is which.

New year resolutions and familial hypercholesterolaemia

02 Jan 2019

The last day of 2018 and a BBC headline reads: "Minority take up 'life-saving' free health check".

The article goes on to quote the national clinical director for dementia and older people's mental health for NHS England saying that the start of a new year was the right time to commit to "taking a simple, free and potentially life-saving step towards a healthier life".

With the new year resolutions to have 'a healthier life' you may have more patients requesting NHS health checks and see more blood test results coming in.

Sinusitis and sore throats

19 Dec 2018

'Tis the season to be jolly. It is also the season for misery with sore throats and sinusitis.

We have included these two common primary care ENT conditions in several previous updates. But, wait, there is more….

Sinusitis: the 2017 NICE guidelines suggest:

Contraception for adolescents with disabilities

12 Dec 2018

It can be challenging enough to navigate the way through adolescence (for adolescents and those who parent/support them). But for young women with disabilities, it can be even more complicated when it comes to managing contraception and pubertal issues.

The onset of menstruation in those with physical and mental disabilities can cause significant distress and distribution. Menstruation can exacerbate pre-existing chronic conditions (e.g. seizure control may worsen just before or during a period).

Adolescents with chronic conditions are as likely as adolescents without medical problems to become sexually active. However, they are significantly more likely to experience sexual abuse.


03 Dec 2018

John was referred to the DVT clinic for his swollen leg. There was no sign of DVT, but further investigation determined that the venous obstruction was due to pelvic lymphadenopathy. John was diagnosed with lymphoma.

Lymphoma is the 6th most common cancer in the UK.

  • Non-Hodgkin lymphoma accounts for 90% of all lymphomas, mostly age >60y.
  • Hodgkin lymphoma has a bimodal age presentation with 2 peaks: age 20-24y and age 70-79y.

Contraception and weight

28 Nov 2018

Women are often concerned about the impact of contraception on their weight. The evidence base is imperfect and limited. The FSRH released helpful statements in 2017 and 2018 regarding contraception and weight.

Key points are:

Chronic pancreatitis

22 Nov 2018

What is it?

Chronic pancreatitis is a rare, incurable syndrome characterised by inflammation and fibrosis of the pancreas. There is loss of exocrine and endocrine tissue, and therefore loss of exocrine and endocrine function.

What causes it?

  • Alcohol (this is a cause in 60% of chronic pancreatitis in men but only 28% in women, for whom it is more likely to be idiopathic).
  • Smoking (thought to be equally as risky as alcohol).
  • Genetic mutations (these also increase the risk of secondary pancreatic cancer).
  • Autoimmune pancreatitis.
  • Idiopathic.

Other risk factors include obesity and longstanding diabetes.

Antiphospholipid syndrome – a reminder!

14 Nov 2018

A review of antiphospholipid syndrome was recently published in the NEJM. If you are anything like me, you may well be struggling to recall any details about antiphospholipid syndrome. So, here is a reminder.

What is it?
It is a systemic autoimmune disease which increases the tendency for thrombosis and adverse obstetric events.

Resilience – why does it matter?

07 Nov 2018

Resilience is a concept that many people struggle to define. However, evidence shows us that many of the elements that make up a ‘resilient’ mindset are key to good clinical practice, making good decisions and minimising error. In times when things seem to conspire against us to make our jobs harder and harder, focusing on our personal resilience should be a priority rather than something left until we have enough time.

Resilience has been defined as ‘adaptability’ or ‘the capacity to recover quickly from difficulties’. I have also heard it described as ‘resourcefulness’ or even ‘mental toughness’. It is often seen as a soft skill and we may have become cynical, observing that resilience seems to be the answer to all the problems currently facing General Practice. However, resilience is anything but soft; we can all probably think of times at work when our clinical decision-making was affected by stress, fatigue or mental exhaustion.

Multimorbidity: frailty and cold weather!

01 Nov 2018

The 2015 NICE guideline on excess winter deaths suggested that primary care team members should, in collaboration with other relevant authorities, identify people who live in cold or hard-to-heat homes.

A recent case-crossover analysis of more than 34 000 deaths assessed if there was any correlation between death and the average 3-day temperature at the time. It reported a statistically significant association between a lower 3-day temperature and risk of death (OR 1.011 per 1-degree Celsius fall (CI 1.007–1.015)). However, this tiny increased risk is highly unlikely to be clinically significant!

Idiopathic normal pressure hydrocephalus – one of the few potentially reversible causes of dementia!

24 Oct 2018

Idiopathic normal pressure hydrocephalus is characterised by ventriculomegaly without marked increase in CSF pressure. It is classically seen in patients >60 years old. Epidemiological evidence in relation to its incidence and prevalence is poor, but a Swedish study found a prevalence of 5.4% in 80 to 89-year-olds.

Immunisations: shingles vaccination – a success story

15 Oct 2018

The shingles vaccine, which is a live vaccine, was introduced in 2013 and is proving to be very effective. A paper in Lancet Public Health looked at uptake rates of Zostavax and disease rates of shingles in England from 2013 to 2016.

Uptake of the vaccine was 72% for the first year and around 60% for the following two years. Since introduction of the vaccine, the incidence of herpes zoster in those eligible for the vaccine has fallen by 35%, and the incidence of post-herpetic neuralgia has fallen by 50%. 

Alternatives to HRT?

10 Oct 2018

Although HRT is the most effective treatment for menopausal symptoms, it is contraindicated in some women, and not tolerated or avoided by others. Many women use complementary and alternative medicines for menopausal symptoms, seeing them as safer, more natural therapies. NICE states that isoflavones (soy) or black cohosh may be effective, but are not significantly better than combined HRT. 

Myeloma: the cancer that has the longest interval between first presentation of symptoms and diagnosis!

03 Oct 2018

Mr Coombes was 68, a keen allotment gardener. He came to see me several times with low back pain and a lack of enthusiasm for digging the potatoes! Initially, it seemed like a musculoskeletal problem, but closer examination revealed tenderness over L5 – he wasn’t one to complain and this raised alarm bells!

Blood tests showed ESR 94, CRP 10, Hb 11.1 and eGFR 46 (no previous results to compare). I wondered about his prostate, but PSA was normal, and his calcium came back raised – protein electrophoresis confirmed a single IgG band. He was subsequently diagnosed with multiple myeloma.

Smoking cessation: is vaping safe?

27 Sep 2018

E-cigarette use was increasing, but has remained steady over the past few years at around 3 million users. However, the evidence regarding their safety hasn’t been as forthcoming. The longest trial of e-cigarette safety has been 2 years. A recent Public Health England report gives some clarity. Here are the headlines from the report:


19 Sep 2018

Occasionally, we see outbreaks of cryptosporidium in the UK. Nationally, there are 3000–6000 cases per annum, with peaks in spring and autumn. It is probably a condition about which we could all do with a reminder!

Cryptosporidium (a protozoan parasite) causes watery diarrhoea with abdominal pain, often with nausea and fever. It lasts much longer than most gastroenteritis, and may relapse once someone is apparently recovering (remember to warn people about this!). The illness is self-limiting and antibiotics are ineffective in the immunocompetent. The exclusion period is 48h after diarrhoea settles, but swimming should be avoided for 2w because of asymptomatic carriage. 

Varicella zoster and ibuprofen

12 Sep 2018

NICE Clinical Knowledge Summaries make clear recommendations that NSAIDs should be avoided for both pain relief and fever management in chickenpox. This is because of concerns identified in 3 studies of an association between NSAID use during an attack of chickenpox and an increased risk of necrotising soft tissue infections and invasive group A beta-haemolytic streptococcal infections. 

Gestational diabetes diagnostic criteria – NICE and now SIGN criteria are new … and are different!

05 Sep 2018

Oral glucose tolerance testing has a limited role because it is complex, expensive and less reproducible . Its main role is in pregnancy. Confusingly, NICE and SIGN have differing criteria for the diagnosis of gestational diabetes. NICE changed the threshold for diagnosis in 2015. The newer SIGN criteria (2017) are in line with recommendations that followed on from the HAPO study, and seem to be used internationally.

Vertigo: differential diagnosis

29 Aug 2018

It is Monday morning. You are already running late and it is only 9:30. Mrs Smith walks hesitantly down the corridor, slowly lowers herself into your consulting room chair and tells you that she is feeling dizzy. Your heart sinks. But maybe, after reading this, it won’t! 

There are many causes of dizziness, but if her ‘dizziness’ is true vertigo, think BPPV and vestibular migraine. 


22 Aug 2018

Imagine a clinical meeting in a surgery not too far away…The practice manager sheepishly asks, “Who is going to be the clinical lead for hyperkalaemia?” The ‘what’?, you think. No one raises their hand, so you volunteer and then wonder what you have let yourself in for! This relates to a recent NHS Patient Safety Alert which may be festering in your post-school holiday inbox. 

We reveal all …and, if you lost at raising-hand-roulette, we offer some help!