About this blog: information for everyone else

Hi there! I’m a GP and this blog consists of the notes I take on journal articles, as part of my continuing professional development. It is intended purely for my own use in recording and remembering the things I learn so that I can refer back to them in the medical setting. While anyone is welcome to read it, please do not take it as any kind of substitute for seeing your own doctor for any medical-related queries or problems.

About this blog: information for appraisers

I use this blog to record my learning points/reflections arising from my CPD. It’s a very handy way of doing it, as it lets me refer back to it easily and use the search function and category menu to find the notes I’ve made on a topic when needed.

My CPD typically consists of a mixture of online modules, articles which I come across in the course of routine journal reading and find useful, answers to DENs that I’ve looked up, and the usual regular courses in CPR and (on a three-yearly basis) child safeguarding. Of the online modules, some are compulsory; the rest I pick based on DENs I identify, either specific (“I wonder what the answer is to this question that arose with this patient?”) or general (“I really need to brush up on my knowledge of skin cancers”).

To read my overall notes for this year, just click on the picture at the top to get to the home page; you can then read the posts in reverse date order (newest first). If you want to check the list of posts on CPD that isn’t from learning modules (as CPD credits for those are recorded separately), those are under the category ‘Credits ____’ with the current year. You can find this by scrolling down the category menu on the right (under the archive menu). I will normally also put in a direct link to this category in my appraisal record.

Hope that’s clear, but happy to discuss any questions at appraisal.

Possibly another side-effect of gabapentinoids

According to a study from the Annals of Internal Medicine, cited in the BMJ, gabapentin or pregabalin use in people with COPD has been linked to an increase in exacerbations. However, there are issues with confounding factors not being properly calculated, so it’s hard to know whether this is an actual issue or not. I guess advice on gabapentinoids remains the same as usual; if trying them at all, keep a close eye on matters to see whether they’re actually of any significant help, and stop them if not.

Cough/cold treatments in children

From a BMJ review, the use or otherwise of various treatments.

Ibuprofen or paracetamol: Helpful. (For symptom relief. They don’t do anything to prevent febrile convulsions.)

Saline nasal irrigation: Technically possibly helpful in that there is some evidence for small short-term benefits, but I suspect in practice this means that any benefits are outweighed by the unpleasantness of trying this in a child. I’m not atually even sure what it means; are we talking saline nasal drops, or an actual irrigation system of some kind?

Decongestants: Currently no evidence of being effective as compared to possible risks. This also applies to nasal steroids and to nasal ipratropium.

Antihistamine/decongestant combos: Might be helpful in 5 – 12-year-olds, but not in <5s. BTW, antihistamines do not actually help sleep.

Antitussives (e.g. dextromethorphan or codeine): Not helpful, and have high rates of side-effects.

Expectorants (e.g. guaifenesin): no evidence either way. (These are the things that are supposed to thin out mucus, as opposed to suppressing the cough reflex.)

Honey: actually does help, although there seems to be some doubt about the methodological quality of the trials. Reduces cough frequency, severity, and duration more than placebo or diphenhydramine. Given its pleasantness and low risk level (in >1-year-olds) compared to most other possible stuff, I’ll definitely recommend it.

Probiotics: Evidence that they might reduce days off school/daycare, but some doubt about the quality of the trials (isn’t there always?)

Fatsia japonica, Pelargonium sidoides, and Andrographis paniculata: Herbal remedies. Evidence for symptom improvement, but no word on possible harms and I’d be highly reluctant to try it on that basis.

Vapour rub: Slight help in sleep, none in cough, and 28% of children felt a burning sensation when it was rubbed on. Not great.

Conclusion: Main evidence for benefit seems to be for Ibuprofen, Paracetamol, and honey. Old ones are the best!

Useful mental health links for patients

From the Teamnet learning modules:

The following charities have a wide range of advice and support on offer for patients and carers:

• NHS — https://www.nhs.uk/mental-health/
• Mental Health Foundation — https://www.mentalhealth.org.uk/
• Depression UK — https://depressionuk.org/
• Mind — https://www.mind.org.uk/
• Samaritans telephone helpline: 08457 90 90 90
• SaneLine telephone helpline: 0845 767 8000. Open from 6 pm to 11 pm every day of the year.

Cholesterol targets

I’ve been aiming for non-HDL reduction of >40% from baseline, as per summary guidelines. Have just read a BMJ review which says that I should also be aiming for >50% reduction of LDL in most patients. Exceptions are:

• Type 1 DM in <35s of <10 years duration, with no other risk factors
• Type 2 DM in < 50s of <10 years duration, with no other risk factors
• 10-year risk of fatal cardiovascular disease 1 – 5% (can be calculated with SCORE prediction tool or similar)

Anyone in those groups is still OK with just having the non-HDL target; others should still have both.

Left unaddressed; how the blue bloody blazes GPs are meant to address these targets on a widespread basis in practice, with hundreds of patients who have in many cases been on statins for years.

Slightly more helpful point: The old advice about taking statins before bedtime doesn’t apply to Atorvastatin or Rosuvastatin, which work just as well whatever time of the day they’re taken.

Management of chronic TMJ pain

The BMJ of 13th Jan (hard copy) has some detailed articles reviewing and discussing the research on temporomandibular joint pain. The conclusions about most effective interventions are:

• CBT augmented with relaxation therapy or biofeedback.
• Therapist associated jaw mobilisation
• Manual trigger point therapy

There was also at least some evidence for CBT on its own, supervised postural exercise or jaw exercise stretching, manipulation, acupuncture, and – reassuringly – ‘usual care’ of home exercises, self-stretching, and reassurance.

The authors concluded that therapies that ‘promote coping’ and ‘encourage movement and activity’ are the most effective.

Optimum dose of iron supplements

Two RCTs found that 60 mg elemental iron on alternate days actually produced better absorption than 60 mg daily. It seems increasing overall iron dose doesn’t increase absorption and can increase side-effects.

Rather than increasing dose, it might be better to look at how it’s given. Take supplements between meals or 30 – 60 minutes before having a meal or consuming tea, coffee, or dairy products. Reducing total amount of tea & coffee per day, and/or stopping PPIs, might also help absorption.

https://www.bmj.com/content/383/bmj-2023-075741

Problems in newborns

Noisy breathing in new babies

TTN can cause mild hypoxia as well as tachypnoea, but can still require supportive treatment with oxygen, so manage breathing difficulties according to presence or absence of red flags rather than definitive diagnosis. Reasons to refer newborns with noisy breathing:

• Suspected infection
• Respiratory distress
• Grunting
• Difficulty feeding
• Persistent stridor
• Signs of congenital cardiac abnormalities
• Other sign of anatomical abnormality on examination

Jaundice

Remember that physiological jaundice in newborns shows up only after the first 24 hours of life. If a newborn is jaundiced in the first 24 hrs, then contact paeds immediately for assessment as it can indicate significant sepsis or haemolysis.

In jaundice in >24-hour-old newborns, arrange a bili level and check this against levels in NICE guidance. From the article it looks as though midwives might be able to do this from a heel prick, but this wasn’t quite clear. If the level is >50 mmol/l below the phototherapy threshold and the baby is clinically well and of gestational age 38 weeks or over, then no need to repeat, although for babies with additional risk factors for jaundice get another visual check in the first 24 hours.

If jaundice persists beyond 2 weeks (or 3 weeks in babies born before 37/40 gestation), refer to outpatient clinic for assessment to exclude hypothyroidism, obstructive jaundice, or infection.

Constipation

It’s normal for newborns to strain at stool and normal for breastfed babies to have infrequent stools. Constipation is defined as ❤ stools a week if the stools are hard and cause distress to pass.

Make sure the baby has passed meconium in the first 48 hours (this includes in utero). If not, refer urgently to paeds to exclude Hirschprung’s disease. Other red flags include:

• Constipation from the first few weeks (article gives this as ‘the first week or two’)
• Abdominal distension with vomiting (look for signs of gross abdominal distension on examination)
• Ribbon stools
• Locomotor delay
• New or undiagnosed leg weakness (not really something you can check for easily in neonates)
• Abnormal perianal appearance (fistulae, bruising, tight or patulous anus, absent anal wink, anteriorly placed anus, multiple fissures)
• Asymmetry or flattening of gluteal muscles
• Central spinal pit (if it looks like a dimple, retract the skin quite firmly over it to be sure)
• Evidence of sacral agenesis
• Lipoma, naevus, or discoloured skin on spinal/lumbosacral/gluteal area
• Sinus hairy patch over spine
• Deformity or abnormal neuromuscular signs of lower limbs

If red flags are excluded, treat with macrogol laxatives first line and lactulose second line.

Oral thrush

Can be treated with nystatin, oral fluconazole or miconazole gel. Make sure to sterilise teats and dummies and to treat nipple thrush in the mother.

BMJ 2023

Weight loss for hip OA: doesn’t seem to work

This was the surprising conclusion of a trial reported at J Am Geriatr Soc doi:10.1111/jgs.18371, which was a cohort study following 5000 older women for 8 years. However, it only seems to have assessed radiographic OA, so it’s not clear whether weight loss would have helped symptoms.

Osteoarthritis flares

Useful snippet of information; flares typically last around 3 – 8 days. So now I know what to advise patients to expect. Best management is not very clear but common sense suggests relative rest for a few days, working up to normal activities as soon as feasible.

Sports-related concussions

Management of suspected sports-related concussions:

• Immediately remove the player from the field of play. This is to avoid second impact syndrome (where someone sustains a second event while still recovering from the first, which can potentially cause fatal brain swelling) as well as avoiding risks to other players. ‘If in doubt, sit them out’.
• Dedicated period of relative rest for 24 – 48 hours, during which time someone else should be with them. This should be both physical and cognitive rest; avoid intensive studying and strenuous mental work, and keep work/online activity/video games to a maximum total of one hour (with screen time kept to the ‘absolute minimum’).
• Phased return to work, education, and finally sport over the next 18 – 19 days.
• No return to competitive sport before Day 21.
• Symptoms recover within two weeks in most cases. If symptoms are still persisting after four weeks, refer to a concussion specialist (this might be a neurologist with a special interest or a sports and exercise medicine consultant). (The exception seems to be headaches, which can persist for several months.)
• Avoid alcohol until symptom-free.

Red flags requiring immediate hospital referral:

• GCS <15 on initial assessment
• LOC
• Focal neurological deficit
• Severe neck pain
• Suspicion of complex skull fracture or penetrating injury
• Amnesia for events before or after the injury
• Vomiting (might not be a danger sign in <12s; use clinical judgement)
• Persistent headache since the injury
• Seizure
• History of brain surgery
• High energy injury
• Anticoagulants
• Antiplatelets other than aspirin
• History of bleeding/clotting disorders
• Intoxication
• Safeguarding concerns
• Continuing professional concerns

(BMJ)