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.

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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.

Posted in About this blog, Credits 2016, Credits 2018 | 2 Comments

Dyspareunia

Note that this may present indirectly; repeated failure to attend cervical screening, persistent dissatisfaction with contraception, describing disgust with her genitals, dissociating during examination.

History

  • Open questions, kept to a minimum; encourage description.
  • ‘When do you get the pain?’
  • ‘Show me where you feel the pain?’
  • ‘When do you think this started? Was there anything else happening around this time?’
  • ‘How would you describe your relationship?’
  • ‘Does your partner have any difficulties with sex?’
  • ‘Are there any other symptoms?’ (burning, itching, abnormal discharge)
  • History of STI or of painful periods

Reflect back emotions: “You seem very tense when you talk about…”

Sudden onset of symptoms can suggest a psychosexual cause triggered by a particular event. Gradual increase is more likely to be physical or anatomical.

Examination

Check for abdominal mass (unusual, but needs to be excluded). Vulvovaginal examination only if the patient feels at ease with the clinician and only to the extent that the patient finds it comfortable. Look for:

  • Tears or fissures (check posterior fourchette; microfissuring might be caused by dermatitis)
  • Herpes lesions
  • Erythema
  • Candidiasis – white plaques
  • Lichen sclerosis or other dermatosis
  • Poor repair/scarring if past vaginal deliveries/episiotomies.
  • Discharge (take swabs if necessary)
  • Signs of vulvovaginal atrophy; hypopigmentation, non-elastic smooth tissue, shiny epithelium. (Remember that this can occur postnatally, especially if breastfeeding; it can also occur in spite of systemic HRT, and local oestrogen may be needed.)
  • Vaginal examination – tender nodules in rectovaginal septum/pouch of Douglas may indicate endometriosis, as may an immobile uterus. Also check for anatomical variants such as vaginal septum

A rapid response to the article added the possibility of urogenital prolapse as a cause, and suggested doing VE in standing position as well as lying down. (The letter also advised specialist women’s health physio as first-line treatment for prolapse.)

Don’t perform a speculum examination on a patient who has vulvodynia or vulvar dermatosis, or if there is a clear psychosexual cause with nothing to indicate a physical cause. If performing speculum examination, beware of offering a small speculum; it can inadvertently reinforce a patient’s concerns about small vaginal size. If a patient asks for a small speculum, ask why she feels she needs one. Do use plenty of lubricant.

In patients with vulval dermatitis or pruritus, consider a ferritin level; 5% of such patients may be iron deficient.

Management

Obviously, work on whatever the problem is (physical, emotional, or both); however, here are some general tips:

  • Perineal massage can be useful for treatment of vulvodynia and of vaginismus, as well as for generally helping women who have been avoiding touching or looking at their genitals get acquainted or reacquainted with them. Recommend doing this twice daily with coconut oil or other inert oil (I have no idea what makes an oil inert rather than otherwise, so I wish they’d given more examples); using the thumb is easier.
  • Avoid allergens. Use an inert oil such as olive oil (aha! Thanks!) for washing instead of soap or shower gel. Avoid biological or perfumed laundry products. Use unbleached, undyed cotton items for sanitary protection. I assume all of this point is meant to be aimed at problems such as dermatitis and maybe vulvodynia? It really isn’t very clear. This just doesn’t sound like good all-purpose general advice for a set of problems which, in the nature of things, is going to involve quite a few people having complex hangups about the problem.
  • Desensitising lubricants such as menthol or water-based lidocaine preparations might be helpful in reducing pain from penetrative sex.

(BMJ practice pointer article from 2018)

Posted in Credits 2019, Gynaecology, Sexual health | Leave a comment

Mirtazapine + SSRIs

I’ve occasionally seen Mirtazapine used as an add-on to SSRIs in resistant depression. An RCT recently showed that adding Mirtazapine to an SSRI or SNRI in resistant depression works no better than adding placebo. That said, the definition of ‘resistant’ here appeared to be ‘first drug not working after at least six weeks’; it still seems possible that there might be a small subgroup of people who just don’t respond to whatever single meds are tried for however long but do respond to a combo. At the very least, however, this shows we need to be extremely cautious about Mirtazapine/SSRI or SNRI combos, since the chances that they actually work better than single drugs are at best low.

Interesting point; typically, if someone isn’t responding to an SSRI, I’ll consider Mirtazapine as second-line monotherapy, not add-on therapy. But if it’s not working as an add-on, would it work on its own? Should we just avoid it?

Posted in Credits 2019, Medication, Psychiatry | Leave a comment

Deprivation of liberty

(Notes from Bluestream Academy learning module)

Note that there are plans to replace the DOLS. The proposed plan is called Liberty Protection Safeguards (LiPS) and should be through shortly.

The ‘acid test’ for whether a deprivation of liberty has occurred from the human rights POV is to look at whether the person in question is:

  1. subject to continuous supervision and control
  2. not free to leave

(Cheshire West judgement, Supreme Court, March 2014)

The reason for this, and the person’s level of compliance with it/lack of objection to it, are considered irrelevant to the application of the acid test.

Conditions for authorising deprivation of liberty are as follows:

  • The person is being treated or cared for in a hospital or a care home. (If they’re being deprived of their liberty in their own home, an application would need to be made to the Court of Protection.)
  • They must be 18 or over.
  • They must have a ‘mental condition’, which is defined as any disorder or disability of the mind other than dependence on drugs or alcohol.
  • They must have been assessed as lacking the capacity to consent to the arrangements being made.
  • The restriction required to receive the care or the treatment they need must be regarded as depriving them of their liberty.
  • Deprivation of liberty must be regarded as in their best interests.
  • They must not be detained in hospital under the MHA.
  • Authorisation of the DOL would not conflict with an obligation placed on the person by the MHA.
  • The DOL does not conflict with another existing authority for decision-making for that person (advance directive, LPA).

 

Definitions:

Restriction of liberty: A term nobody has quite managed to define, referring to milder and more acceptable forms of what in a more comprehensive form would be deprivation of liberty. ‘Restraint of liberty’ seems to be another, and equally poorly-defined, term.

Supervisory body: this is the local authority. (This is in England, where I work. In the rather unlikely event of me ever working in a hospital in Wales, the supervisory body there will be the local health board. In care homes in Wales, it’s still the LA.)

Managing authority: the organisation (hospital or care home) responsible for the care of the person deprived of their liberty.

Standard authorisation: authorisation issued by the supervisory body to permit lawful deprivation of liberty.

Urgent authorisation: authorisation issued by managing authority to permit lawful deprivation of liberty.

Relevant person: the person who needs to be deprived of liberty.

 

Application for a deprivation of liberty safeguard

In my work, the typical situation in which this will come up will be in the care home. In that setting, the managing authority will be the person registered under the Health and Social Care Act 2008 (which I would guess would be the manager). (In a hospital, it would be the NHS body that runs the hospital. In a supported living situation applying for DOLS would not be permitted and a deprivation of liberty would have to be authorised by the Court of Protection; if it’s felt that a DOL might be required then ask the local authority to seek authorisation.)

The assessment involves various different things, including consultation with the person, the carers/professionals involved in their care, and their family/friends, or, if they have none, an IMCA.

DOLS authorisations have to include a duration, and the maximum is one year. If the circumstances change during that time, the authorisation should be reviewed, and ended if appropriate. Authorisations also have to include any conditions that the managing authority must follow.

Managing authorities can issue an urgent authorisation themselves if the situation is urgent. However, in such a case they must apply for a standard authorisation at the same time, and the assessments must be complete within seven days.

Named friends/family members must be consulted:

  • By the managing authority before they apply for a standard authorisation, and also, where possible, before an urgent authorisation. The proposed care plan must be discussed with them to see whether they agree that it’s appropriate and that the deprivation of liberty will be necessary.
  • By the assessor, to get their opinion on whether the proposed plan is in the relevant person’s best interest.
  • If anyone challenges the authorisation or care plan after it has begun, in order to get their views.

They should be informed in writing:

  • To let them know whether the authorisation has been issued, after the assessments, or not.
  • When the authorisation comes to an end.
  • If a new authorisation is requested after any reviews/challenges to the care plan.

(It is of course good practice to keep them informed at all points.)

 

Safeguards under a standard authorisation

  1. The person must have a relevant person’s representative (RPR), appointed as soon as possible. The best interest assessor is the one who needs to find someone able and willing to do this. It will normally be a family member, but if no-one is available then the supervisory body has to appoint someone who can be paid to undertake the role. Their job is to a) maintain contact with the person deprived of liberty, and b) represent and support them in all matters relating to the deprivation of liberty. They have two important powers: they can insist on having the standard authorisation reviewed by the supervisory body, and they can challenge the deprivation of liberty in the Court of Protection.
  2. If their RPR is not someone paid to undertake the role, they have the right to support of an IMCA, who will also support the RPR. The IMCA’s role is to help both the person and their RPR understand the authorisation and their rights, and to support them in exercising their rights as above if needed.
  3. As well as the RPR being able to insist on a review, anyone involved in the person’s care can ask for a review at any time.
  4. The person themselves, as well as their RPR, has the right of immediate access to the Court of Protection.

Someone with concerns about unlawful DOL should talk to the managing authority, preferably by putting concerns in writing. The managing authority must normally respond within 24 hrs, in writing.

 

Challenging an unlawful deprivation of liberty

If you think someone is being deprived of their liberty unlawfully, inform the hospital or care home. Standard letters are available for that purpose. The managing authority should in the first instance either apply for authorisation for the care regime or change it immediately; they must normally respond within 24 hrs.

 

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Talking to people about their diabetes

Judith Handley, a health policy geek with Type I diabetes, has written an article for the ‘What your patient is thinking’ section of the BMJ, on alternatives to asking people with diabetes whether they’re well-controlled (to which she always feels like replying “No, you just can’t take me anywhere”). Suggestions:

  • How are things going with your diabetes?
  • How are you feeling about your diabetes at the moment? (which offers support instead of focusing on blood sugar control and potential judgement)
  • Are you having any problems with your blood sugar?
  • Is there anything you’re finding particularly challenging?
  • What are your ideas on how to handle that?
  • What is most important to you right now?

Also, of course, don’t forget to use ‘person-first’ language; and for goodness’ sake be tactful enough not to ask people whether they ‘suffer with’ diabetes or another illness, when what you actually want to know is whether they have it!

Posted in Communication, Credits 2018, Diabetes | Leave a comment

When not to use HbA1c for maintenance

We’re hopefully all familiar with the list of situations in which HbA1c might give a false reading when used to diagnose diabetes (short version; any situation in which the glucose might have undergone rapid recent change), but it’s also important to remember situations in which it shouldn’t be used to monitor glucose. This recent BMJ article lists the situations:

Situations in which HbA1c might be falsely low:

Any situation in which the average red blood cell age is decreased:

  • Haemolytic anaemia from any cause
  • Haemorrhage
  • Erythropoetin therapy (causes reticulocytosis, so I suppose you get all the young whippersnappers of RBCs skewing the age average)
  • CKD (this is, apparently, the effect of renal anaemia/erythropoetin deficiency. Although I’m not sure that made sense to me; if erythropoetin therapy decreases average red blood cell age, why would erythropoetin deficiency have the same effect?)
  • Possibly HIV infection. (Also, see effect of the meds, below.)

Situations of decreased glycation:

  • High dose vitamin C or vitamin E
  • Alcohol
  • Ribavirin and some other antivirals
  • Some antibiotics: e.g. trimethoprim/cotrimoxazole. (Wait – does that mean we can’t use HbA1c for monitoring in anyone who’s on prophylactic trimethoprim? Would it be a problem at the 100 mg od dose?)

Also:

  • Nucleoside reverse transcriptase inhibitors decrease HbA1c readings as a side-effect.

Situations in which HbA1c might be falsely high:

Not surprisingly, situations in which the average red cell age is increased.

  • Splenectomy
  • Aplastic anaemia, or other conditions in which the percentage of reticulocytes is decreased.

 

There are different options available where HbA1c isn’t suitable. Apart from fructosamine, which of course I’d heard of already (measures total glycated plasma protein), there is also glycated albumin, and something called total glycated haemoglobin. However, if this became an issue I would discuss with either the biochemistry team or the diabetic team rather than decide myself which method to use.

 

 

Posted in Credits 2018, Diabetes | Leave a comment

STOPP (Screening Tool of Older People’s Prescriptions)

I’ve just been reading through this, having decided to check it out after reading a mention of it in the latest BMJ. (Deprescribing is a particular interest of mine; it has the satisfying feel of clearing out a bunch of clutter and taking it down to Oxfam.)

Most of the points on it I already knew (for the most part, they’re good prescribing rules for anyone). Here are a couple that stood out, however:

  • Loop diuretics are not recommended for ankle oedema, unless there is also some kind of evidence that this is secondary to CCF, renal failure, liver failure or nephrotic syndrome. Apparently, in other cases, it’s usually better to try leg elevation and possibly compression hosiery. I’m not usually in too much of a hurry to try loop diuretics anyway due to the polyuria, but it’s good to have this emphasised.
  • When using PPIs for umcomplicated peptic ulcer or erosive oesophagitis, only use the full dosage for 8 weeks or fewer; after that, the dose should be reduced or discontinued altogether. This is very useful, because we do tend to keep those going out of concern or inertia, and they do have long-term effects.

 

Posted in Credits 2018, Elderly Medicine, Medication | Leave a comment

Flozins and COPD inhalers

That’s two separate subjects, not one, whose link here is that they were both the topics of useful papers in this week’s BMJ.

The first was on possible adverse effects of flozins (sodium-glucose cotransporter-2 inhibitors). The paper was a very large cohort study comparing the occurence seven possible serious adverse events in new users of flozins and new users of GLP-1 agonists. The ones that came out as statistically significant, both on the side of increased risk of the flozins, were:

  • Lower limb amputation (NNH 1.6/1000 person-years)
  • DKA (NNH 0.7/1000 person-years)

The ones that weren’t statistically significant were fractures, AKI, serious UTI, VTE, and acute pancreatitis.

Interesting… this suggests the problems are due to flozins managing slightly worse diabetic control than GLP-1 agonists. I checked the full paper; HbA1c was among the factors adjusted for, but maybe the control is worse in slightly more subtle ways? I’m never in a rush to use flozins purely because they are so new, and if I did it would be on the advice of the diabetic clinic, so, although this is interesting, I guess it won’t change my practice.

The second study was a systematic review and meta-analysis comparing dual therapy (or monotherapy) with triple therapy in COPD. I’ve wondered for a while how helpful ICSs actually are when a patient is already on LABA + LAMA, so this was interesting to me. According to this paper, three trials compared the two.

  • Quality of life scores were marginally worse on triple therapy (just under two points difference, SGRQ score), but the paper didn’t explain whether this was clinically significant or not. (Also, of course, this one could easily be confounded by indication. The article really isn’t that clear about which studies are which, so I gave up on trying to dig out the original studies to see whether they were RCTs or cohorts; it was just taking more time than I had.)
  • Exacerbations were less frequent on the triple therapy than on LABA + LAMA (0.78 rate ratio)
  • Pneumonia was more frequent on the triple therapy (1.53; I think this is risk ratio, but the study wasn’t clear).

No NNHs were given, so I’m actually kind of stuck as to how the numbers shook out overall.

Sigh. Both of these looked really interesting, and now I’ve gone through them I’m not so sure I got anything useful from them. Except to beware prescribing, because it is filled with dragons.

Posted in BMJ, COPD, Credits 2018, Diabetes, Endocrinology, Medication, Respiratory | Leave a comment