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Key BMJ learning points from recent BMJs

In cases of errors please read the original articles before using the information below to influence clinical decison making!

2021

May 6th

Hypothyroidism and sub clinical hypothyroidism

Hypothyroidism effects 7% of older adults (10 x more common in women than men)

Consider testing if

  1. Convincing symptoms
  2. Newly diagnosed hyperlipidaemia
  3. Found to be macrocytic
  4. Suspected dementia
  5. 6 monthly if subclinically hypothyroid and TPO antibody positive
  6. Annually if they have Down’s syndrome
  7. Certain drugs e.g. Lithium and Amiodarone require TSH monitoring
  8. Infertility investigation

 

Be aware – greater risk in Type 1 diabetics, coeliac disease and in obese patients (14% of obese patients are hypothyroid)

There is no value in measuring T3 or rT3 levels

Subclinical hypothyroidism = raised TSH with normal T4

Repeat RSH in 3 months if still raised and T4 normal check TPO antibodies

If -ve – repeat TSH if patient develops hypothyroid symptoms (only 2.6% will go on to become hypothyroid each year)

If +ve repeat TSH 12 monthly  or if they develop symptoms (4.6% go on to develop hypothyroidism each year)

Rx

The starting dose, frequency of dose titration, and the optimal full replacement dose should be based on several key parameters including1:  
(1) Patient age -  e.g. older patients: start lower and titrate more slowly.
(2) Weight (1.6-1.7 mcg/kg ideal body weight).  Note: based on available research,
       Ideal Body Weight for height NOT actual body weight
(3) Cardiovascular status (positive history of coronary artery disease warrants initiation
      at a very low dose and very slow titration),  
(4) General health.
(5) Concomitant medications (see examples below).
(6) Severity and duration of hypothyroidism.

Up titrate every 4 to 6 weeks until TSH back in the normal range

 

May 22nd

Based on a network meta-analysis of 764 RCTs

Newer Rx for type 2 DM – how to use GLP-1 agonists and SGLT-2 inhibitors to reduce the risk of cardio-renal disease (regardless of Hba1c). Cardio-renal disease risk reduction produced by these drugs is independent of their impact on glycaemic control.

Now good evidence that GLP-1 agonists and especially SGLT-2 inhibitors when added to usual care decrease the risk of CVD and CKD (all cause death, MI, Stroke, HF and end stage renal failure).  There is no increase in severe hypoglycaemic risk and they may produce weight loss.

SGLT-2 clearly associated with increased genital infection and possibly increased risk of DKA but no evidence of increased risk of digital amputation.

GLP-1 – possibly associated with severe GI events but no evidence of link with pancreatitis

Rx based upon risk stratification

  1. No CVD disease, No CKD. Less than 3 risks factors for CVD (e.g. age > 60, male, CKD or CVD FH, uncontrolled Hba1c, smoker, uncontrolled HT, total cholesterol > 5.2 with HDL < 1)  - No to SGLT-2 inhibitors of GLP-1 agonists
  2. No CVD disease, No CKD. More than 3 risks factors for CVD – Yes to to SGLT-2 inhibitors
  3. CVD or CKD present - Yes to to SGLT-2 inhibitors or GLP-1 agonists
  4. CVD and CKD present - Yes to to SGLT-2 inhibitors or GLP-1 agonists

 

GLP-1s may be used if they have CVD, CKD, or both

SGLT-2 inhibitors may be used any one with > 3 risks factors for CVD or if they have established CKD or CVD

If a choice between the two, choose SGLT-2 inhibitors

You may also consider SGLT-2 inhibitors in Type 2 diabetes in those patients keen to reduce their risks of developing CVD or CKD (primary prevention).

 

May 29th

AF management and diagnosis NICE

  • All-cause mortality lower with DOACs than warfarin.
  • Lower risk of stroke with DOACs vs warfarin.
  • Lower risk of major bleeding with DOACs vs warfarin.
  • Lower risk of intracranial bleeding with DOACs vs warfarin.
  • Apixiban 5mg bd was the most effective (and cost effective DOAC) for reducing stroke and all-cause mortality and also one of the safest with the lowest incidence of major bleeds and GI bleeds.
  • Anticoagulation needs to be used to reduce stroke risk.
  • DOACs are 1st line choice of anticoagulation for most patients unless they have mechanical heart valves, moderate to severe mitral stenosis or significant CKD.
  • Rate control should be offered for the majority (1st line).
  • CHA2DS2Vasc score still used to assess stroke risk.
  • ORBIT has replaced HAS-BLED as a major bleeding risk assessment tool.
  • Stratify stroke risk for paroxysmal AF and Atrial flutter in the same way as for permanent AF.
  • Increased use of left atrial appendage ablation (see later) for those who don’t respond to conventional therapies.

ORBIT requires HB, eGFR, age, sex, current use of antiplatelet, prior hx of GI bleeding, intracranial bleeding or haemorrhagic stroke. It calculates the absolute risk of a major bleed.

The calculator my be found at https://www.mdcalc.com/orbit-bleeding-risk-score-atrial-fibrillation#evidence

ORBIT Score

Risk group

Bleeds per 100 patient-years

0-2

Low

2.4

3

Medium

4.7

4-7

High

8.1

NOTE: Even if bleeding risk is high anticoagulation should still be considered and the ORBIT score is used to inform patient decision making

June 5th

Congenital CMV infection

CMV infection is common and usually a self-limiting illness with generalised symptoms, such as fatigue and lymphadenopathy in healthy individuals. In pregnant women it increases the risk of miscarriage, still birth, developmental abnormalities in utero and post-natal/childhood. Also, sensorineural deafness becomes increasingly common with age. CMV infection worldwide occurs in 1 in 100 to 200 live births. It is usually transmitted through contact with saliva or urine from infected young children.

Mainstay of prevention is through advice

Pre-natal maternal advice

  • Avoid contact with young children’s saliva
  • Avoid kissing on lips, try cheeks or forehead
  • Avoid shared food or utensils including cups and straws
  • Wash hands after wiping children’s noses or changing nappies
  • Avoid outing pacifiers in your mouth e.g. ‘cleaning’ them after they drop on the floor by putting them in your mouth!

 

June 12th

Dupuytren’s disease

Common (3 to 5% of the population), especially in Northern European races. More common in men and usually develops between 50s to 70s. Starts with skin dimpling and nodules in the palm which may be painful (pain often settles with time). 1/3 progress to significant contractures and disability. 80% of patients have a FH. More common in diabetics. Possible more common in smokers and alcohol misuse). Not related to vibrational tool use.

Ectopic disease – feet (Ledderhose disease( and penis (Peyronie’s disease).

Collagenase injections no longer used in Europe due to lack of availability rather than safety concerns.

Splinting does not help.

Physio and USS may help in early stages.

Refer if causing significant disability or (a basic crude test) if patient unable to press hand flat upon a table.

Surgery has a ‘high’ relapse rate

Needle fasciotomy – done in outpatients under LA. Cost effective. Low complication rate. Quick recovery. Not suitable for severe disease. 40% relapse at 3 years and 8-% relapse at 5 years.

Fasciectomy - Cutting out of Dupuytren’s cord – slower recovery needing post op physio. 20 % recurrence at 5 years.

Dermofasciectomy – more extensive surgery – longer recovery but relapse rate < 10% at 5 years.

Fasciectomy

 

General measure to prevent PPE facial dermatoses

  • Clean skin with soap free cleanser
  • Apply emollient 30mins prior to wearing PPE
  • Silicon based barrier tape applied to nasal bridge and cheeks e.g. siltape (OTC)
  • Wipe skin under PPE with silicon based barrier wipe (OTC)
  • Make sure PPE is a good fir and not too tight
  • Maintain good oral hygiene
  • Stay well hydrated

 

June 19th

GPs advised by NHS England to consider seeing all under 5s with respiratory symptoms due to concerns over lack of exposure to non-covid respiratory infections. Government guidance recommends all pyrexial children or those with a continues cough be tested for covid and stay at home until they get the result BUT this should not take precedence over clinical assessment. Prolonged or severe symptoms should not be attributed to covid in children.

 

CRP and procalcitonin as markers of bacterial infection

CRP is made in the liver, it induces complement activation and facilitates phagocytosis by macrophages. It starts to rise around 12 hours and peaks at 2-3 days in bacterial infection. It may remain elevated for several days, even if the infection has resolved. It can be used in the community in adults to help differentiate bacterial pneumonias and rationalise antibiotic prescription. It’s a cheap test and is widely available.

Procalcitonin (PCT) is used in hospitals (not widely available and expensive) to help identify children with serious bacterial infection. It starts to rise within 3 hours, peaks at 6 hours and falls to normal within 24 hours one infection resolves.

NB. CRP and PCT lacks diagnostic sensitivity to rule out bacterial infection in Primary Care, as the prevalence and pre-test probability of serious bacterial infection is so low.


June 26th

Opiod Use Disorder

Common. Increased morbidity (Psycho-social, HIV, Hep B, Hep C etc) and mortality (esp due to O/D). Often injected. Most common in N America, N Africa and Middle East.

2 question screening

  1. How many times in the last 12 months have yu used drugs other than alcohol (>6 = +ve).
  2. How many times in the last 12 months have you used drugs more than your meant to (>1 = +ve)?

Four key aspects – Impaired control, social impairment, risky use and pharmacological dependence.

 

Treatment

Little or no evidence

Evidence for brief interventions in Primary Care is mixed. Most effective in patients with low risk use.

Psycho-social interventions e.g. self-help groups, counselling and residential treatment can help (but much lower than pharmacotherapy).

Medically supervised withdrawal over a short period is not recommended due to high rate of relapse and risk of O/D.

 

Strong evidence of benefit

Pharmacotherapy has a wealth of evidence demonstrating benefit (both mortality and morbidity). Long term pharmacotherapy is the mainstay of treatment for OUD and the key drugs are methadone, buprenorphine and extended-release naltrexone.

Methadone and Buprenorphine are the most effective.

Methadone, orally, is highly effective in deceasing morbidity and mortality and illicit drug use. This is the target NOT Rx cessation. Long term methadone Rx is therefore the norm. It requires more monitoring than buorenorphine as its long half life increases the risk of or respiratory depression.

Buprenorphine, daily sublingual or monthly sc injection

Beware, due to high opiate receptor binding affinity it will displaces opiates and may trigger ‘precipitated withdrawal’, so not started within 8 to 12 hours of short acting opiate use e.g. heroin and usually started at a low dose.

If up-titration fails to control cravings then switch to methadone

No evidence that illicit drug testing in Rx programmes improves clinical outcomes. A positive test may be useful to discuss if a dose increase is warranted, if they are experiencing withdrawal.

Naltexone is not as good as Buprenorphine or methadone in treating OUD.

 

Harm reduction services: teaching safe injection, having naloxone available, not sharing needles, safe space and or injection equipment made available, injecting slowly, snorting rather than injecting etc

 

July 3rd

Investigating a raised CK

CK is a biomarker for muscle damage. Most raised CKs are physiological (due to exercise especially if the patient is dehydrated – settles back to normal over 3 to 7 days). Other causes include: Medications (Statins, Macrolid antibiotics e.g. clarithromycin, Antifungals e.g. ketoconazole, Retinoids and hydroxychloroquine ), Endocrine disorders e.g. hypothyroidism, Metabolic disorders e.g renal impairment, Rheumatological disorders e.g. SLE and Rh Arthritis, Dermatomyositis and some rare genetic disorders e.g. DMD.

Stable, asymptomatic raised CK < 4ULN needs no investigation

Don’t start statins if pre Rx CK is stable and raised above 5x ULN

Myalgia and persistently raised CK warrants investigation e.g. Cr & Es, LFTs, TFTs, CRP, adj calcium, vitamin D, urine dip test for haematuria.

CK > 10 x ULN needs urgent referral re ? Rhabdomyolysis (impaired renal function, dip test +ve > than one + for haematuria with no blood on MSU)

Statin myalgia (‘normal’ CK i.e. < 4 x ULN) / myopathy (raised CK > 4 x ULN)

Occurs most often in the first 3 months of Rx but may occur with later dose increases or drug interaction (5% of statin users develop myalgia or myopathy). Less common with newer generation statins (Atorvastatin, Rosuvastatin etc). If CK normal just try lowering the dose or stop until symptoms resolve and re-try (92% of patient on re-challenge remain on the statin by 12 months). If recurs try a lower dose or a newer generation statin, if still a problem consider very low dose statin regimes. Note: If CK > 10 x ULN immediately stop statin and inx re ? Rhabdomyolysis.

 

July 10th

Assessing the red eye

Useful questions

Is it painful or just uncomfortable? Onset and progression?  Is it unilateral or bilateral? Associated with headache? Has vision been affected? Any contact lens wear?

 

Red Flag questions / signs

Pain of recent onset, little relief or disturbing sleep

Ipsilateral headache (same side as red eye)

  • Reduced vision
  • Photophobia
  • New onset diplopia
  • Unilateral swelling around the eye
  • Reduced eye movement
  • Proptosis
  • Tender eyeball
  • Asymmetric or unreactive pupil
  • Hazy cornea
  • Systemic symptoms and signs

 

Video consultations are very effective (more so than telephone) as it allows patient assisted examination. Although VA checking apps on phones have not been validated, they can be useful for highlighting differences in Vas. Robust safety netting is essential.

Lumbar spinal stenosis

More common than you think. Usually presents in the over 50s. Presents with leg and / or buttock pain/paraesthesia on walking or prolonged standing. Relief with sitting down or leaning forward (shopping trolley sign).  Cycling does not trigger the pain. Patients may also have low back pain or motor weakness. May cause significant problems with day-to-day activities (shopping, recreation, socialising etc with consequent psychological harms). Neurological examination is normal and pedal pulses usually present.

Differentials to consider – vascular claudication, hip OA and trochanteric bursitis. These can usually be excluded on Hx and Ex.

No role for routine imaging. May be appropriate if surgery being considered.

Physio and home exercise is first line treatment with 30-50% of patients with mild to moderate symptoms achieving significant improvement in symptoms. No role for long term analgesia. Refer pain clinic if symptoms severe or neurological deficit. Evidence for short term relief with spinal injection but no evidence of benefit with steroid injection.

 

July 17th

Glioblastoma

Rare, 1-3 cases in a GPs career. It is the commonest primary brain tumour. Despite surgery, chemo and DXR median survival is 14 to 16 months.

50% diagnosed after presenting to A&E

20% present with new onset seizures

Most have seen their GP multiple times

Headache over weeks +, worse on lying down (hence present on waking), evolving minor personality change, changes in cognition, progressive weakness, co-ordination, wt loss etc. Also, may have symptoms of raised ICP – nausea, visual obscuration, headache worse with coughing etc.

Symptoms increase in frequency and severity over time.

Acute onset headache is very unlikely to be due to tumour

 

Diagnosis of TB in primary Care

In UK reactivation of latent disease is most common.

Increased risk

  • Close contact: Prisons, Homeless, Migrants and household contacts
  • Immunodeficiency: HIV, DIABETES, immunosuppressives including steroid
  • People with substance abuse disorders: drugs or alcohol
  • People working on prisons, healthcare and mining
  • Children under 5
  • People from high prevalence areas in the world

 

Pulmonary TB is most common

Symptoms: chough, haemoptysis, night sweats, fatigue, wt loss BUT many are asymptomatic

 

Invx – CXR is first line screening tool +/- sputum PCR or NAAT (Nucleic Acid Amplification Test). Note sputum AFBs can take 4 to 6 weeks, useful re treatment but less so for initial diagnosis.

 

July 24th

WHO guidance on drugs in severe Covid

Recommendation not to use: Ivermectin, Hydroxychloroquine, Lopinavir-Ritonavir, Remdesivir

Recommendation to use: Systemic steroid (Dexamthesaone) and or Monoclonal Ab Rx which blocks cytokine activation (Tocilizumab and Sarilumab).

 

Nipple pain in breast feeding

Poor latching on or attaching to the breast is the commonest cause.

Cracked or sore nipples – avoid nipple shields and avoid resting the nipples in mid feed. Simply apply expressed milk post feeds, change breast pads after very feed, cotton bra, MW or HV to check baby position and attachment as these are contributory factors

Little evidence for topical lanolin or oral pro-biotics

Nipple thrush – usually new onset sharp bilateral nipple pain during and after breast feeding sting up to a few hours – increased risk post antbx or baby with oral thrush

Other nipple conditions such as eczema. Beware that in patients with coloured skin eczema may be brown, violaceous or grey!

Mastitis - ? erythema, ? fever, ? persistent pain

Don’t forget chest conditions - costochondritis

Rare causes – nipple vasospasm on exposure to cold (may have a hx of Raynauld’s)

Autoimmune disease such as thyroiditis or diabetes

Achy breast pain usually due to engorgement, blocked ducts or mastitis

 

August 7th

Understanding weight loss and Type 2 diabetes remission

Type 2 DM develops when a personal tolerance for fat levels in the liver and pancreas are exceeded. Weight loss of around 15KG (or 10%) will often induce remission in patients within 10 years of diagnosis.

As fat accumulates within the liver it reduces hepatic insulin sensitivity, so increasing glucose output and triglyceride output by the liver. Sustained high triglycerides especially VLDL leads to increased pancreatic ectopic fat which in turn causes a potentially reversible de-differentiation of Beta cells with consequent reduced insulin output. Weight loss undo’s this spiral into diabetes.

Remission > 2 years is achievable for at least 1/3 of recently diagnoses type 2 DM who achieve significant weight loss (approx. 15kg). Ethnic minorities achieve the same remission rates with weight loss.

 

Wt loss is key, the nature of the diet an individual uses to achieve and sustain weight loss is less important. Some evidence that low CHO diets may be slightly better than low calorie diets (about 1kg difference at 12 months). Portion control is also important. Evidence for fasting also exist with the 5:2 diet (2 days a week daily calorie intake reduced to 500 – 700) or restricted eating windows in the day (a 6 to 8 hour window within the day). There is some evidence that avoiding ultra-processed foods may help with weight loss and glycaemic control.

 

21st of August

NICE - Long Covid

New medical nomenclature; Symptoms 0 – 4 weeks = acute covid, 4-12 weeks = ongoing symptomatic covid-19 and > 12 weeks = post covid-19 syndrome. It effects all age groups in adults with increased risk in women and patients with co-morbities.

Post covid-19 syndrome prevalence following symptomatic and asymptomatic infection seems to be about 2%. Most patient will eventually get better.

Like acute covid -19, long covid can involve multiple organs especially respiratory, cardiovascular, neurological, musculoskeletal and renal.

Fatigue: An unrelenting exhaustion/weariness which saps a person energy, motivation and concentration is one of the most common symptoms.

Dyspnoea: Fluctuating levels of dyspnoea are also common and can be very disabling.

Cardiovascular: Chest pain, possibly due to myocarditis, is a common problem, as is new onset postural orthostatic tachycardia syndrome (POTS) due to autonomic dysfunction.

Cognitive and mental health: Symptoms are diverse but many patients describe ‘brain fog’ with difficulties in concentrating, remembering and processing thoughts. Headaches and sleeplessness are also common. Anxiety, depression and PTSD are also common.

Financial & social: Long covid has implications for work, finances, relationships, parenting, caring and all aspects of daily living which have to be explored in order to best help patients with long covid.

Useful patient national and local resources

https://www.homerton.nhs.uk/covid-recovery-and-rehabilitation/

https://www.yourcovidrecovery.nhs.uk/

https://www.wypartnership.co.uk/videos/long-covid

Don’t forget the value of pulmonary rehab, Physio, OT, your Social Prescriber and the regional long covid clinic see https://www.wypartnership.co.uk/application/files/1516/0520/0632/Long_covid_slides_10.11.20_v4.pdf

Subacute bowel obstruction

Consider in recurrent colicky abdo pain associated with vomiting and minimal diarrhoea lasting more than 24hours. Beware - Bowel sounds may be normal, abdominal distension may not be marked (and is difficult to spot in obese patients) and the patient may be passing flatus and minimal overflow diarrhoea, there may also be stool in the rectum.

Common small bowel causes are adhesions and hernias.

Common large bowel causes are faecal impaction, cancer, diverticular disease and sigmoid volvulus

So in addition to the usual GE Hx taking ask about prior bowel habit and recent changes, prior abdo and pelvic ops, any hx of diverticular disease, any groin swellings in any patient with colicky abdo pain and vomiting.

Always check hernial orifices in patients with colicky pain!

If suspected send to SAU as abdo CT is the diagnostic test of choice (not plain AXR).

September 11th

Use of medical cannabis or cannabinoids

NICE – strong recommendation, it should be restricted to clinical trials only!

This BMJ – expert panel recommendation following 4 systematic reviews

Related to non-inhaled medical cannabis or cannabinoids (oral or topical)

Balance between harms and benefits is close

Small improvements for some patients regarding pain control and sleep quality

It does not improve emotional well-being or social functioning/well-being

Small number do get neuropsychiatric SE such as cognitive impairment, altered attention, dizziness or nausea.

THC and CBD are the most common cannabinoids found in plants. THC is the psychoactive form which makes cannabis users high. CBD is not psychoactive. Most medical cannabinoids have a mixture of the two or a higher CBD:THC ratio.

 

September 18th

CKD

Adjusting eGFR for ethnicity is no longer advised. Used four-variable kidney failure risk tool rather than eGFR to decide on referral for CKD.

Four-variable Kidney failure risk equation for patients with eGFR in CKD3 to 5 range.

Uses: Age, Sex, eGFR, urine ACR (watch units) and patient location

https://reference.medscape.com/calculator/308/kidney-failure-risk-equation-4-variable

Calculates 5-year risk of ESRF. Refer if > 5%.

 

In diabetes optimising glycamic and BP control is key but note new guidance. In type 2 DM with ACR > 30 mg/mmol and optimised dose of ARB/ACE offer SGLT2 inhibitors (flozins).

 

Referral criteria for CKD3 to CKD5

  1. 5 years risk of ESRF > 5% using four-variable equation.
  2. ACR > 70mg/mmol unless known to be caused by DM and already appropriately treated.
  3. ACR > 30 mg/mmol with haematuria
  4. Sustained fall of eGFR > 25% in 12 months and a change in CKD stage.
  5. Year on year sustained fall in eGFR > 15
  6. HT poorly controlled despite four anti-HT agents
  7. Suspected genetic causes of CKD or suspected renal artery stenosis.

 

Frequency of monitoring

CKD3a annual but if ACR > 30mg/mmol 6 monthly

CKD3b annual but if ACR raised then 6 monthly

CKD4 6 monthly but if ACR > 30 then every 4months

 

September 25th

NICE: Acne

Advise patients

  1. Use a non-alkaline synthetic non comedogenic detergent to clean their face twice a day.
  2. Avoid oil based moisturisers
  3. Avoid oil based makeup
  4. If using makeup to remove at the end of the day

Consider psycho-social consequences? may need referral for counselling

1st line Rx for mild to moderate acne (uses fixed combined treatments)

12 week trial of: Adapalene/Benzoyl peroxide or Tretinoin/Clindamycin or Benzoyl Peroxide/Clindamycin. Improvement usually noticed at 6 to 8 weeks, review at 12 weeks.

Warn patients re clothes bleaching and skin irritation with Benzoyl peroxide

Warn patients re photosensitivity and skin irritation with topical retinoids or clindamycin

Warn patients to stop a topical retinoid 1 month prior to trying for pregnancy

Consider adapalene/benzoyl peroxide + oral doxycycline or Lymecycline if acne areas are difficult to reach. Antibiotic cessation should be considered 3 months and should not be prescribed longer than 6 months.

 

At 3 month review

If acne cleared consider stopping.

If not cleared try 12 weeks of another first line agent (if moderate to severe consider adding in an oral antbx but if an oral antbx was part of the first Rx then refer dermatology)

 

Refer if the patient has

Mild to moderate acne that has not responded to two complete courses of Rx

Moderate acne that has not responded to topical + oral Rx

Acne conglobata or nodulocystic acne

Acne with scarring or pigmentation change

Urgent same day referral if they have acne fulminans

 

October 2nd

HRT is not associated with increased risk of dementia

Biliary Colic

Biliary colic commonly presents with colicky RUQ or epigastric pain and may be associated with vomiting. Pain may radiate to the right shoulder. Pain not relived with antacids or bowel movement. More common in women, increasing age, obesity, FH and history of recent intentional weight loss.

Differential – Reflux, Peptic Ulcers,  Renal colic,  Cholecystitis, Cholangitis, Pancreatitis,  PE or ACS

Around 10% of adults have gallstones. 80% of whom will not develop symptoms.

After an uncomplicated attack of biliary colic there is a 50% chance or recurrence in 12 months and 1 to 2% chance of gallstone complications per annum (Cholecystitis, cholangitis, pancreatitis etc).

Analgesics of choice are NSAIDs _/- paracetamol

If gallstone complications or pain not settling = admit

Remember – persistent pain, systemic upset, jaundice, peritonism = admission!

If pain settles – they need LFTs and routine USS. Refer for elective lap cholecystectomy. \little evidence that lifestyle changes  reduces recurrence risk.

Other bloods to consider are Cr&Es, FBC, CRP, BS etc

 

October 9th

Poorly controlled asthma – Global definition = daily symptoms, nocturnal awakenings, some limitations of daily activities, two or more exacerbations per year.

UK – similar but use of a reliever > 3x a week is a slightly different indicator

Global Initiative on asthma has different steps to the UK!

MART is the basis of treatment as it reduces hospitalisations or A&E attendance compared to standard Rx but only a small amount (< 1 in 100 difference between MART vs Standard Rx ). It reduces the need for oral steroids compared to standard Rx (2 in 100 difference between MART vs Standard Rx).

 

Budesonide with femoterol e.g. Symbicort is commonly used for MART – Maintenance is bd with prn use up to a max daily dose of 12 inhalations (for Symbicort).

 

Evidence for Montelukast is not very strong in patients with poorly controlled asthma (Despite UK guidance of a trials for 1 to 2 months if SABA and lo dose ICS not working)

SE with Monteleukast – nightmares, aggression and depression

 

Newer add in asthma Rx = LAMas, Azithromycin and biological therapies (specialist initiated)

 

Considerations at review

Patient understanding

Recent changes in Rx?

Changes in environment (e.g. new pets, smoking, weight gain, change in occupation)

SEs of current Rx

Concordance

Effective delivery

Step up

Individual asthma action plan

 

October 16th

NICE: Covid Vaccine Induced Thrombocytopaenia and Thrombosis (VITT)

VITT is rare. 15 per million post first doses of covid vaccination and 2 per million post second doses. Incidence in 18-49 year olds is 2x that of > 49 years.

Caused by the development of antiplatelet factor 4 antibodies post vaccination leading to intense activation of platelets and the coagulation system. Symptoms develop 5 – 30 days post vaccination and include severe unusual headache, pinprick bruising, shortness of breath, ankle swelling or severe persistent abdo pain due to thrombotic complications.

Cerebral vein thrombosis occurs in half of patients. And a 1/3 have thrombosis at multiple sites.

Patients should be counselled at vaccination to seek help if they develop:

  • Severe headache which gets worse and is not relieved by painkillers
  • Unusual headache, worse on lying down or accompanied with blurred vision, nausea or vomiting, weakness or difficulties with speech
  • Shortness of breath, chest pain, leg swelling or persistent abdo pain
  • New pinprick bruising or bleeding

Refer immediately to A&E if VITT suspected and the patient is ill (or MAU if well, as they need same day bloods and imaging).

Rx is non heparin-based anticoagulation

 

Paruresis 'Shy Bladder' – Difficulty passing urine in public toilets. Can be very socially inconvenient and has psychological consequences. More common than you would think (prevalence 3 to 16%). Eeffects both men and women. It can be treated through counselling and support see https://www.ukpt.org.uk/

 

October 23rd

BRCA mutations in men

BRCA1 and 2 code for DNA repair proteins. There re many mutations and only some increase the risk of cancer. They are inherited in an autosomal dominant manner, so men and women are equally affected. Cancer predisposing BRCA variants in men increase the risk of prostate cancer, breast cancer and pancreatic cancer. This is especially so for BRCA2 cancer predisposing variants. The prostate cancer tender to develop earlier and be more aggressive. With BRCA2 cancer predisposing variants the risk of developing prostate cancer is I in 4 at 75 and more than 1 in 2 at 85 years.

European guidance suggests PSA screening from age 40 but interval period not specified. The Impact Study which is currently running is performing annual PSA on men 55 years to 69 years with cancer predisposing BRCA and preliminary results shows screening detects cancers earlier.

Both BRCA1 & 2 cancer predisposing variants increase the risk of male breast cancer, particularly BRCA2 which produces an 8% life time risk. Men are advised to be breast self-aware. No current plan for male breast screening in this group.

Both BRCA1 & 2 cancer predisposing variants increase the risk of pancreatic cancer. There is no evidence of benefit from MRI screening as yet.

 

Don’t forget men with BRCA cancer predisposing variants have children and 1 in 2 daughters will inherit there BRCA cancer predisposing variants and its increased risks of breast and ovarian cancer. So, a suggestive family hx, particular if the relevant cancers occur at a young age, warrants discussion around genetic counselling referral.

 

October 30th

Colorectal bowel screening

NHS screening programme is based on the Faecal Immunochemical Test (FIT test), starting at age 60 and repeated every two years up to the age of 74. In some higher risk individual screening starts at 56 years. Patients 75 or over may request a FIT test but will not be routinely sent for. The FIT test requires just a single faeces sample.

Most cases of Colo Rectal Cancer (CRC) are sporadic but 20 to 30% are familial. Screening is reducing CRC mortality.  In America screening starts above age 50 and is repeated every 1-2 years. FIT testing measures human haemoglobin in the stool.  It has a sensitivity (ability to identify those with disease) of 79% and specificity (ability to designate those that don’t have disease) of 94%.

 

Private tests patients may ask for in the UK

Blood test – a blood test for methylated septin 9 DNA has a sensitivity of 69% and specificity of 92%, so not as good as FIT testing. Also, more expensive and not available on the NHS.

Multi-target DNA faecal test – Detects haemoglobin AND DNA shed in the stool. Its sensitivity (ability to identify those with disease) is 92%, so better than FIT BUT its specificity (ability to designate those that don’t have disease) is around 85%, so leading to more unnecessary colonoscopies. It costs more but screening is less frequent at 1 to 3 years.

 

Nov 6th

Pfizer Covid booster works!

Study from Israel of 700,000 patients given a 3rd Covid booster (Pfizer) 5 months post second dose matched to a control group who just had the first two doses. In the study 231 patients in the control group admitted to hospital vs 29 who had the 3rd (booster) vaccination (re deaths 44 vs7).

 

Antenatal care

GPs should advise patients that after 28/40 they should not sleep supine as it is associated with increased risk of SFD and still birth. Consider using pillows to maintain their position while sleeping.

Pelvic girdle pain effects 1 in 5 pregnant women and can be eased through physiotherapy and non-rigid lumbopelvic belt.

Unexplained bleeding post 13/40 requires referral and consideration for anti-d immunoglobulin if they are Rh D-negative and at risk of isoimmunisation.

Routine USS after 28/40  is not recommended in low risk pregnancies

Rates of maternal mortality and still birth are highest among women and babies from deprived areas, and higher among black (4x), mixed ethnicity (3x) and Asian women (2x) and babies compared to those who are white

 

Nov 12th

HPV vaccination – a resounding success

HPV immunisation for children was introduced in England back in 2008. The relative fall in Cx cancer rates for the vaccinated vs an unvaccinated co-hort  revealed, for those vaccinated age 16 to 18 (RR of 34%), those vaccinated 14-16 years (62%) and 12-13 years (87%)! Similar relative risk reductions were also seen for CIN 3.

 

November 20th

Obstructive Sleep Apnoea

Common, affecting 5% of UK adults. In addition to sleepiness patients may present with insomnia, poor concentration or insomnia rather than apnoea.

The Epworth score is designed to assess sleepiness and has relatively low sensitivity and specificity for OSA. Still OK to use for screening but should not be solely used to guide referral. The STOP-Bang questionnaire has higher sensitivity. This relies on Snoring, Tiredness, Observed apnoea, high blood Pressure, Bmi >35, Age, Neck size > 40cm and Gender.

https://britishsnoring.co.uk/stop_bang_questionnaire.php

Consider screening for OSA in patients who report two or more of: Snoring, witnessed apnoea, unrefreshing sleep, waking headaches, unexplained sleepiness, nocturia, sleep disturbance/insomnia or cognitive dysfunction. Refer to sleep clinic if the diagnosis is suspected.

Increased risk of OSA in patients who are obese or have; Type 2 DM, Resistant HT, AF, Moderate to severe HF or asthma, PCO, Down’s syndrome and hypothyroidism.

Home oximetry for diagnosis (low sensitivity and high specificity) is slowly being replaced by respiratory polygraphy (Pox, heart rate, nasal airflow and thoracic/abdominal movement) which has higher sensitivity and high specificity.

In a patient with troublesome snoring or OSA– review and stop sedative medication e.g. opiates or TCAs, reduce alcohol intake, weight loss interventions, smoking cessation and to avoid sleeping supine. Don’t forget DVLA driving advice in OSA.

Mandibular advancement devices for patients with mild OSA or who decline / cannot tolerate CPAP. They can be used in adult patient with good dentition and absent gum disease.

Mandibular advancement advice PILealfet https://www.guysandstthomas.nhs.uk/resources/patient-information/acute/mandibular-repositioning-device-for-sleep-apnoea.pdf

CPAP – 1st line treatment for mild to severe OSA. Two types; fixed level CPAP (most common) and auto-CPAP (used in some patient with mild OSA) which is an intermittent triggered form of CPAP.

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