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

This blog consists of notes made on any learning points I come across in the course of CPD and want to remember/look up later. The two main sources for this are on-line learning modules, and articles which I identify in the course of journal reading as meeting a learning need. Credits for the former are obviously counted elsewhere, so I’ve grouped the latter in a separate category in order to estimate the learning credits I’ve obtained from structured reading. You can find all posts in that category for the 2013 – 14 appraisal year here.

Posted in About this blog, Credits 2016 | 2 Comments

Lyme disease: points from NICE guidance

Some useful points from a BMJ summary of the NICE guidance (note that I’m keeping this brief, as I’m trying not to duplicate points I already have):

Incubation period

May appear as much as 3 months after the initial tick bite (previous figure I had was up to 1 month). Minimum is still apparently 3 days. Usual incubation period is between 1 and 4 weeks.

Diagnosis

An ECM rash is considered diagnostic; just go ahead and treat without testing. Otherwise, the test is ELISA followed up by immunoblot if positive.

If symptoms are persistent and the ELISA was done within 4 weeks of symptom onset, recheck the ELISA 4 – 6 weeks later. If symptoms remain after twelve weeks, proceed to immunoblot even if ELISA was negative.

If the immunoblot is positive, that counts as a definite diagnosis. If it’s negative and symptoms are continuing, consider alternative diagnoses and also consider referral to specialist.

Treatment

Recommended treatment periods are now 21 days in most cases (28 for arthritis or acrodermatitis chronica atrophicans, but that’s something I’d be unlikely to be treating without seeking advice; the main take-home point for me here is that ECM or non-specific presenting symptoms should be treated with 21 days). Doxycycline is first-line choice for either of those two presentations, Amoxicillin second-line. Third-line is Azithromycin, which has a slightly shorter duration requirement; 17 days.

For children over 12, the recommendation is still doxycycline. Ditto for 9 – 12-year-olds, but in that situation it’s unlicensed although accepted specialist practice.

(I’ll look doses up if needed rather than writing them all out.)

 

(Having read this article, I then went back and reread my previous notes on the subject for revision of the various signs of middle/late-stage disease, so think this counts as a full credit rather than half.)

Posted in Credits 2018, Infectious Diseases | Leave a comment

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)

Posted in Credits 2018, Gynaecology, Sexual health | Leave a comment

LUTS aren’t an indication for prostate cancer screening

Another useful pointer from the 5th May BMJ; It is not clear whether LUTS in men are associated with prostate cancer, so, given the potential harms of screening, LUTS should not be used as an indication for checking PSA as a screening test.

(That said… I’ve read that a PSA over 4.2 (I think that was the figure) is an indication for finasteride or equivalent, as it indicates an increased risk of eventual urinary retention. So I do tend to do them for that reason. It’s worth being aware of the drawbacks, though.)

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Don’t use bath additives for children’s eczema

A simple and extremely useful study result; in children with eczema, don’t bother prescribing those additives that you put in the bath water. The BATHE study studied children from 1 to 11 with eczema (‘very mild’ eczema was excluded) who were being given standard eczema management with emollients, topical corticosteroids, and use of emollient instead of soap; the use of three different bath additives was compared with the use of no bath additives, in a randomised setup. The use of bath additives didn’t help.

Posted in Credits 2018, Dermatology, Medication | Leave a comment

Overactive bladder in men

Examine for retention, prostatic hyperplasia/poor rectal tone, and neurological signs.

Check urinalysis. Consider C&S, PSA, glucose, and urodynamics.

Treatment:

Behavioural changes: Scheduled/double voiding, avoidance of irritants, training of pelvic floor muscles, smoking cessation. Online patient resource from EAU. Downloadable list of bladder irritants/potential substitutes; the most important are alcohol, tobacco, caffeine, artificial sweeteners and chocolate, but there are quite a few others, including aged cheese, sour cream, and yoghurt, none of which I would ever have anticipated being a problem.

Note that there is some evidence for some herbal remedies, but not recommended by NICE at this point.

Pharmacological treatment: Often first-line is treatment for bladder outflow obstruction symptoms; anticholinergics can be added to that. Oxybutinin has the most SEs and it’s now recommended that it be avoided. The authors said they often start with either fesoteridine fumarate or darifenacin hydrobromide, but we didn’t get a cost discussion. The risk of acute retention is minimal, but pre-existing urinary retention is one of the contraindications (others include closed-angle glaucoma, ileus/bowel stenosis/severe IBD/toxic megacolon, myasthenia gravis, and tachyarrhythmias. People can respond differently to different formulations, so it’s worth trying a different one if no response to the first.

As an alternative, beta-3 agonists (e.g. mirabegron) are well tolerated, but the cost-effectiveness is currently unknown.

Follow-up is recommended 4 – 6 weeks after starting or adjusting therapy.

Failure of medical therapy generally warrants specialist referral.

 

BJGP June 2018

Posted in Credits 2018, Incontinence, Urology | Leave a comment

Does Vitamin D deficiency cause fatigue?

This question came up regarding a patient. The National Osteoporosis Guidelines on Vitamin D weren’t helpful, so I went onto PubMed. I found the following:

  • This study found that vitamin D levels were negatively associated with fatigue in young Iranian nurses.
  • This study found that the presence of Vitamin D deficiency was associated with a greater likelihood of reporting fatigue (although the degree of deficiency didn’t correlate with the degree of fatigue. At least I think this is what it was saying; I only have the abstract, which is slightly unclear.)
  • This case report is of a case of hypersomnia without other apparent cause that was found to be associated with Vitamin D deficiency and improved rapidly when the deficiency was treated. Obviously only one case report so of limited use, but still interesting.

And, when it comes to treatment:

  • This double-blind RCT showed a significantly greater likelihood of improvement in fatigue symptoms in deficient patients with Vitamin D as compared to placebo, with an NNT of approximately 5. In this study, the initial levels were <20 mcg/l.
  • This RCT did not show any benefit of Vitamin D on fatigue in patients with CFS. However, as far as I can tell from the abstract, initial Vitamin D levels weren’t tested so we don’t know whether the patients were deficient or not.
  • This randomised trial showed Vitamin D supplementation to be of help in deficient patients with fatigue following renal transplantation, but as far as I can see it’s not clear whether the patients were blinded, or what the regime was.
  • Finally, although it’s about depression rather than fatigue, I thought it worth noting that this small RCT showed that Vitamin D supplementation also improved mood.

In conclusion, there seems to be at least some evidence that Vitamin D deficiency can manifest as fatigue and that supplementation can help.

Posted in Credits 2018, DENs | Leave a comment

Stable angina – NICE guidelines

New official guidelines for assessing possibly cardiac chest pain; check for the following three features of the pain.

  1. Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
  2. Precipitated by physical exertion
  3. Relieved by rest (or by sublingual GTN) within approximately 5 minutes.

The presence of all three features can be diagnosed as ‘typical’ anginal chest pain. Two out of three is classified as ‘atypical’. One or zero is ‘non-anginal’ and does not require further investigation unlses there are other factors of concern in the history or risk factor profile.

Ask about resting chest pain or rapidly progressive symptoms, which would indicate unstable angina or possibly ACS.

Investigation is now by CT coronary angiogram, with positive or inconclusive tests being followed up by functional testing with either stress echocardiography, stress perfusion cardiovascular magnetic resonance, or nuclear perfusion imaging. Angiography should now only be used in cases where other tests are inconclusive or show proximal or extensive coronary disease. CT coronary angiogram has very high sensitivity and thus is excellent for a rule-out test.

Medical therapy is still the first-line treatment.

(BJGP, April 2018)

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