BMJ summaries from our GPSTs - keeping you up to date
2013 summary of BMJ key points (click)
2015 summary of BMJ key points (click)
2016 summary of BMJ key points (click)
2017 summary of BMJ key points (click)
2018 summary of BMJ key points (click)
Peri-ocular eczema – Rx with twice daily emollients, ointments preferable to creams. Use soap substitutes. Once daily 1% hydrocortisone, ointment preferable to creams, for 7 to 10 days. Consider topical tacrolimus in patients with recurrent periocular eczema or one resistant to treatment, If infected, swab and treat with a combination of topical and/or oral antibiotics depending upon severity.
Seborrheic dermatitis – Associated with the yeast Malasezzia.. If recurrent or recalcitrant consider screening for immune deficiency. Use ketoconazole shampoo. Leaving the suds in contact with the scalp for 5-10 mins and use the suds to wash the face. A topical antifungal with or without low potency steroid may be applied twice daily for 7 to 10 days.
Dual Anti-Platelet Therapy after high risk TIA or minor ischaemic stroke – TIA within 24 hours and ABCD2 score 6 to 7 (high risk) - consider a loading doe of clopidogrel of 300mg and then 75mg a day for 10 to 21 days and daily aspirin 75mg (no loading dose) in the long term. DAPT not to be used in major stroke due to risk of intracranial bleeding.
HIV Pre-exposure prophylaxis PreP – Recommended in patent at high risk of HIV e.g. HIV negative men who have condomless sec with men of unknown HIV status. Trans people who are HIV negative and have condomless sex and HIV negative individuals who have condomless sex with individuals known to have HIV (who do not have a suppressed viral load). Availability is increasing in the UK via sexual health clinics. Efficacy is dependant on adherence. It does not protect against other STDs. If affords a 70% risk reduction. An alternative to daily PreP is on demand PreP in which meds are taken in the 24 hours before intended sex and continued until 48 hours after sex.
Dysfunctional breathing in adolescents with asthma – this may cause symptoms which can be confused with poor asthma control and ‘resistant asthma’. Consider it in patients with inspiratory difficulties, tightness in the throat, resistant wheeze and anxiety symptoms. Often patient have psycho-social stressors. They may have increased agitation or tremor after beta agonist use. Breathing re-training exercises may be helpful http://www.uhs.nhs.uk/Media/Controlleddocuments/Patientinformation/Respiratory/Breathing-pattern-disorders-patient-information.pdf or www.breathestudy.co.uk.
Vulval itch – Is common. Frequent causes include eczema, contact dermatitis, seborrheic dermatitis, genital psoriasis, lichen planus and lichen sclerosis. Common skin irritants which may matters worse; latex condoms, lubricants, spermicides, toiletries including bubble baths, soaps etc and urine leakage.
General advice – avoid scratching, avoid tight fitting clothes, use loose cotton underwear, avoid irritants as detailed above. Use simple emollients and soap substitutes, consider an antihistamine for itch-scratch suppression. Treat urinary incontinence.
Dermatitis – general measures + moderate potency topical steroid dialy for 7 to 10 days
Seborrhoeic dermatitis – Antifungal/mild steroid for 1 to 2 weeks
Genital psoriasis – moderate potency steroid followed by low potency steroid. Once daily for up to 4 weeks and then step down to twice weekly maintenance.
Lichen planus – High potency steroid daily for 4 to 8 weeks then tapered according to response followed by maintenance Rx with lower potency steroid.
Lichen sclerosis – Very potent steroid once a day for 1 month, alternate days for 1 month, twice weekly for 1 month and follow up after 3 months.
Thyroid disorder in the elderly (>65 years) – Those will subclinical hypothyroidism - over 5 years 58% stayed the same, 40% resolved and only 2% went on to overt hypothyroidism. Those with sub clinical hyperthyroidism - 64% stayed the same and 32 % reverted to normal with only 4% developing overt hyperthyroidism.
Mild hyponatreamia – increased risk of falls in elderly and fragility fracture
<125mmol/l or unwell = admission, 125 to 129 = discuss with on call physician re ? needs admission, 130 – 135 – manage in primary care
Common drug causes = thiazides, loop diuretics with ACE or spironolactone, SSRIs especially citalopram, antipsychotics and antiepileptics such as carbamazepine and PPIs. Check their meds as many can cause hyponatreamia. Try stopping rx if possible, with follow up bloods. If only mild, chronic and patient well and no clear remedial cause ? no treatment necessary.
Euvolaemic = ? drugs, respiratory infection, malignancy or CNS causes
Hypervolaemic = ? HF, Liver failure or renal failure
Hypovolaemic = ? drugs, GI losses or adrenal insufficiency
Usual invx = Ur & Es, Plasma and urine osmolality, urinary sodium, 9am cortisol, TFTs + invx of other potential underlying illness
Osteonecrosis of the jaw – fewer then 1 in 1000 patients on oral bisphosphonates will suffer this. Seems most likely after dental extraction. Patients should have a dental check and any remedial treatment before starting bisphosphonates and on going check ups while on treatment. They should be warned to seek urgent dental advice if they develop jaw pain or feel exposed bone through the gum. One yearly iv infusion of bisphosphonates, for those unable to tolerate oral do not have a higher risk of osteonecrosis of the jaw. Risk for oral bisphosphonates increases after four year duration of use. Denosumab is also associated with osteonecrosis of the jaw.
Subclinical hypothyroidism – TSH raised but < 10 and T4 normal on two or more tests. 60% will normalise without intervention over 5 years. It’s common. NB in past advice was to Rx if symptomatic BUT 20 to 25% of the normal population will report one or two symptoms – fatigue, muscle cramp, cold sensitivity , constipation, low mood etc! No evidence Rx improves symptoms.
TSH > 10 = Treat
TSH 4 to 10 – (non pregnant or no multiple severe symptoms) consider watch and wait
Local guideline – 2 x TFTs to confirm, then check TSH at 3 and 6 months and there after annually to identify resolution or any progression to overt hypothyroidism (most important in TPO +ve patients who have a higher risk of progression to hypothyroidism).
Temporal Arteritis – 50% have temporal headache, 30% jaw claudication, 30% visual symptoms, 50% PMR symptoms, 50% fatigue or anorexia or weight loss. Most patients are over 50 years of age, average age of onset is 70 years.
80% will have an ESR > 50
Always check for abnormal visual fields and VAs and ask re blurring, diplopia or visual loss – if present refer immediately to ophthalmology.
Refer patients urgently to rheumatology & instigate your local TA Bx pathway but start high dose oral steroids (oral pred 60mg) with aspirin cover and a PPI straight away. Methotrexate or tocilizumab may be used for steroid sparing or treating recurrent relapse. Note, despite a steroid tapering regime 40% of patients will relapse.
Vestibular migraine – episodic vertigo lasting hours to 3 days, NOT usually associated with hearing loss and NOT usually exacerbated by particular head movements. Often but not always associated with headache or nausea or photo/phonophobia. ALWAYs consider the posterior circulation stroke at time of first episode. Patients usually have a prior history of migraine and motion sickness. Triptans and/or prophylaxis work well.
Cannabinoid hyperemesis – More common than you think! Seen in chronic cannabis users and presents with cyclical nausea and frequent vomiting with patients compulsively taking hot showers and baths (as this relieved the symptoms). Rx is cannabis cessation.
Recurrent VTE – The risk of recurrent VTE after discontinuation of initial anticoagulant treatment is high. 10% in the first 12 months with a cumulative risk of 25% at 5 years and 36% by 10 years. The risk is greater in men than women and in patients with a history of proximal DVT or PE. So should remain an active problem in GP records.
Oesophageal cancer – Incidence increasing. Usually occurring over the age of 55 with peak incidence in 80s. Effects men more than women. Smoking and alcohol predispose to SCC while obesity, reflux and Barrett’s oesophagus predispose to adenocarcinoma.
New onset dyspepsia is the commonest early symptom and obstructive symptoms suggest a later presentation. Over half of patients present with advanced disease. Other than red flags consider the diagnosis in patients over 55 years with treatment resistant dyspepsia, abdo pain with anaemia, raised platelets and upper GI symptoms.