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.

Posted in About this blog | Leave a comment

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

Reflux in infants

(BMJ 2017;357:j1802, supplemented by checking the original guidance)

Not to be referred to as GORD unless the symptoms are interfering with the baby’s quality of life or causing complications (poor weight gain, difficulty sleeping, recurrent chest infections). Otherwise, it’s physiological GOR, minus the D.

Red flag symptoms

  • Frequent projectile vomiting – forceful enough to stain a wall or land across a room. This is associated with pyloric stenosis, especially if starting from third or fourth week in a typically hungry infant who’s failing to gain weight.
  • Bilious vomiting – can indicate intestinal obstruction and requires urgent surgical referral.
  • Blood in vomit, unless swallowed blood from nipple crack etc.
  • Vomiting unrelated to feeding – can be secondary to RICP and hence a sign of NAI.
  • Bulging fontanelle – also sign of RICP
  • Constipation/loose stools – might indicate CMP or lactose intolerance. (This is included on the list of symptoms requiring paediatric referral, which surprises me; surely a trial of a hydrolysed formula is the best first step?)
  • Blood in stool – CMP-induced enterocolitis (again, not sure why requires paeds referral rather than trial of hydrolysed formula)
  • Onset after 6/12 – unlikely to be reflux, may be infection
  • Persisting after 1 year – suggests alternative diagnosis
  • Systemic symptoms (may be infection or RICP)

Management

Usually conservative.

  • For bottle-fed babies, try the following:
  1. Reduce volumes by about 20% but increase frequency to maintain appropriate total daily amount of milk.
  2. If that isn’t successful after 2/52, offer a trial of thickened formula (Aptamil anti-reflux, Enfamil anti-reflux, SMA Staydown).
  • For breastfed babies, advise seeing lactation expert/community midwife.
  • Try keeping babies in an upright position for the first hour or so after feeding, except when sleeping.
  • Always remember to ask how parents are coping.

If these measures fail, consider a trial of alginate. If that doesn’t work, and if the child seems distressed or has poor growth or choking symptoms as well as the vomiting, try a two-week trial of either H2 antihistamine or proton pump inhibitor. If that still doesn’t work, stop the medication and refer to secondary care.

Don’t use prokinetics without specialist advice.

Posted in BMJ, Credits 2017, Paediatrics | Leave a comment

Chondrodermatis nodularis helicis

I just checked some photos and confirmed my suspicions that this is what one of my patients has, so am making some notes on the advice:

  • Main thing is to avoid pressure on the ear during sleep. Cutting a hole in the pillow can help but sounds a bit drastic. Using a piece of foam rubber or a bath sponge, cutting a hole in that, and holding it to the head with a headband, sounds more feasible. Purchasing a silicone splint from a dermatology organisation (not sure where; maybe BAD?) can also be done but is obviously more expensive.
  • Protect from cold and wind; wear a warm hat when outdoors. (Luckily not an issue at the time of year that I’m writing this.)
  • Ulceration can be treated with petroleum jelly or with antibiotic ointment under a light dressing. In view of antibiotic resistance issues, I prefer the thought of the former.
  • Steroid injections, cryotherapy, and collagen injections are all options, although obviously not ones I could try.
  • GTN ointment 2% bd can be used in severe cases.
  • Surgical excision is an option, but there’s a 10 – 30% recurrence rate.

(DermnetNZ site, plus emedicine)

Posted in Credits 2017, Dermatology, Skin lesions | Leave a comment

Huntington’s disease

(BMJ module; information from Dr David Crawford, consultant in neuropsychiatric genetics at St Mary’s, Manchester. Module chosen as I have a patient with Huntington’s who is developing increasing problems.)

Huntington’s causes a combination of progressive motor, cognitive, and psychiatric symptoms. It’s also a catabolic disease, meaning that patients can lose a lot of weight in a short time (over and above that caused by swallowing difficulties).

It is probably the most slowly progressive of all the neurodegenerative disorders, with a typical course of around 15 to 25 years from onset to death. Typical age of onset is around 40 or soon after, but there is a huge range, with about 5% of cases showing up before age 21 (juvenile Huntington’s) and a small percentage starting only in their 60s or 70s.

Motor symptoms

  • Hyperkinetic symptoms: involuntary movements which typically start with affecting the fingers and toes and, over a number of years, become larger in amplitude and begin to affect more central muscles (choreiform movements). Typically, these symptoms eventually plateau and then decline again as the hypokinetic aspects (see below) become more often.
  • Hypokinetic symptoms: slowing of movement and reduced co-ordination.
  • Dysarthria (difficulty speaking) often progressing to complete muteness in the late stages
  • Dysphagia

Cognitive symptoms

  • Slowing of thinking
  • Impaired attention/concentration. (In the late stages, this can be severe enough to impair cognitive functioning almost completely, leading to a situation where a patient will have quite severe dementia but occasionally will have enough of a flash of concentration to come out with quite a cogent statement.)
  • Difficulties with executive function (planning and organising, problem-solving)
  • Mental rigidity and repetitive thinking (typically middle to later stages)
  • Loss of motivation (eventually overwhelming)

Psychiatric symptoms

  • Irritability (very common, often one of the presenting symptoms)
  • Low mood and anxiety
  • Impulsive behaviour, impulsive anger
  • Loss of drive and motivation (later symptom; eventually the most predominant)

Treatment

Symptomatic only:

  • Chorea: dopamine-blocking or dopamine-depleting drugs (i.e. neuroleptics or tetrabenazine). Downside is that these worsen the bradykinesia and can slow thinking; tetrabenazine can also cause depression.
  • Low mood/anxiety and irritability: SSRIs in high doses (typically top end of recommended range; may also need high doses mirtazapine at bedtime to augment).
  • Late-stage irritability and aggression: neuroleptics (see above caveat).
  • Catabolism: very high-calorie diet
  • General support

Outcome

Eventual death from intercurrent infections. It should be noted that, prior to this, patients can typically live out in the community (with appropriate support) for much longer than was previously the case, due to the better symptomatic treatment.

Posted in Neurology | Leave a comment

Postponing menstruation, and amenorrhoea with contraception

Like most GPs, I’ve happily dished out prescriptions for norethisterone when a woman wanted to postpone her period, on a basis of hey, what harm can it do? More than I thought, it turns out; according to an article in April’s JFPRHC, norethisterone is actually metabolised to ethinylestradiol, and taking 5 mg tds is therefore equivalent in terms of thrombosis risk to taking a 30 mcg COC. In most cases, of course, this won’t matter, but it does mean that giving norethisterone doesn’t have any benefits over the COC as far as risks go.

This has the following implications:

  1. If a woman who wishes to postpone menstruation can safely take a COC, she might as well just do so; it’s simpler to take than norethisterone and doesn’t have the anecdotal side-effect of causing heavier bleeding when the period does start. (The exception, I suppose, would be if she had had previous side-effects with COCs and wished to try something different.)
  2. If a woman who wishes to postpone menstruation is at increased thrombosis risk, then her best option is probably to try 10 mg methylprogesterone three times daily started ‘before the onset of menstruation’ (it doesn’t say how far before). There is no published evidence to support its use and, anecdotally, it may be less effective than norethisterone, so it’s really just a case of doing something just in case it helps.

The article also had an interesting list of the percentage of women achieving amenorrhoea over a 90-day reference period on various contraceptives:

  • Mirena – 23.6% at 3 years
  • Jaydess – 11.6% ‘over time’
  • Nexplanon – 20% ‘over time’.
  • Depo-Provera – 55% at 12 months
  • Sayana Press (new form of injectable DMPA) – 56.5% at 12 months
  • Standard COC in 21/7 regime – <1%
  • Estradiol COC with shorter hormone-free break – 19.4 – 31% ‘over time’. (Interesting. Didn’t know that.)
  • Desogestrel POP – 20% at 12 months. (I’d always been told it was 50%, so I guess that must be over a longer time period? Or maybe I’ve just been told wrong!)
  • Traditional POPs – 3% at 12 months (again, I’d been told 10% overall, so hopefully few more over time).
Posted in Credits 2017, Gynaecology, JFPRHC | Leave a comment

Bits and bobs

Useful bunch of motley learning points from the 15th April BMJ:

A double-blind trial reported in NEJM has looked at the effects of treating borderline thyroid results (raised TSH with normal T4) in the elderly. It didn’t show any benefit in terms of symptoms.

Blood pressure control can go too far. A new paper has reanalysed the results from two previous trials into an antihypertensive in >55s with a history of various arteriopathies (stroke, TIA, coronary artery disease, peripheral artery disease) or of DM with organ damage. The analysis showed that mean achieved systolic BPs <120mmHg were associated with increased risk of cardiovascular outcomes other than MI and CVA, and mean achieved diastolic BPs <70mmHg were at increased risk of cardiovascular outcomes including MI and also heart failure. Could possibly be a reverse causality effect, but still… treat BPs with some caution. More isn’t always better.

Short-term oral corticosteroids aren’t harmless. This paper in the BMJ reported on a dataset study looking at use of oral corticosteroids for less than 30 days. In patients having such a course, the short-term incidence of sepsis, VTE, and fracture increased 2 – 5-fold above background levels after initiation of the steroids.

And another study in the same issue came up with an ingenious response to one of life’s practical problems – getting a urine sample from a baby. The trick is to soak a gauze swab in cold fluid and gently use it to stimulate the suprapubic area while someone else hovers with a sterile container. In almost a third of cases, this was successful in obtaining a urine sample within five minutes. (Oddly, I’d just been reading Dick Francis’s novel ‘Straight’, in which a stableboy is trying unsuccessfully to get a urine sample from a racehorse for drug testing, so I immediately wondered whether the same technique would be worth trying in those cases?)

Posted in BMJ, Cardiovascular, Credits 2017, Endocrinology, Hypertension, Medication, Paediatrics, Thyroid | Leave a comment

Hip protectors

Several of the residents at the care home where I work have recently suffered falls, and one enthusiastic young staff member raised the issue of whether hip protectors would be helpful. Which was a very good question. I vaguely remember reading a BMJ article some years back in which hip protectors were discounted as being of minimal practical use, but, since the question had been raised, I thought I should brush up on the matter.

I started by plugging ‘hip protectors’ into Search on Pubmed, started reading through the main reviews that popped up, and found a reference to a Cochrane review on the topic. This looked promising, so I looked it up and found their conclusion was that there was ‘moderate quality evidence’ for the following:

In older people living in nursing care facilities, providing a hip protector
– probably decreases the chance of a hip fracture slightly
– may increase the small chance of a pelvic fracture slightly
– probably has little or no effect on other fractures or falls

In older people living at home, providing a hip protector
– probably has little or no effect on hip fractures

(Cochrane Database Syst Rev 2014;(3):CD001255)

Of course, in this context what I’m looking at is the result for older people in nursing (or residential) care facilities, so this looked promising. I looked further to find out what was meant by that ‘slightly’, and apparently NNT works out at about 100. (This means, in plain English, that if you’re an elderly person in a care home wondering what the odds are that wearing hip protectors will prevent a hip fracture you otherwise would have sustained, they’re about 1 in 100. Or, to put it another way, if you could give 100 such people hip protectors and then look into a crystal ball to see what would have happened if they hadn’t had them, for probably 99 of those people the outcome would be much the same, but one lucky person would have their hip fracture prevented by the protectors.)

(The proportion may in practice be even lower, because there was then some complicated stuff about the relative risk changing if the studies at highest risk of bias were excluded, but they didn’t rework the NNT. The RR changed from 0.82 to 0.9, which I think makes the NNT come out at half the amount, which would be one in 200 – but feel free to correct me.)

I went through the details of the studies to see whether the intervention had been in high-risk patients only or in care home residents generally, and the answer was that it depended on the study. (Also, of course, different studies had different criteria for what counted as ‘high risk’.) It’s therefore possible that recommending hip protectors only to patients at high risk of falls would lead to greater effectiveness overall.

One notable point was that a lot of care home residents didn’t want to wear the protectors long-term. In some cases, this was due to side-effects such as skin irritation; in a lot of cases, it seemed to be because they either didn’t understand the significance or weren’t that bothered.

Another point is that there are different types of hip protector – hard, soft, and types that are supposed to shunt the force away from the hip, or something impressively complicated-sounding. I did some arithmetic with the figures given and found that the RR for the three groups that only used soft protectors (there was one that used both hard and soft) came out as 0.38, and the RR for the two that used shunters came out as 0.44. Obviously those are a lot better than the RR given for the total, but I don’t know whether I’m missing anything obvious that I should have taken into account when analysing this. Have to say that soft ones sound more comfortable, though I don’t know whether it makes any difference in practice.

Conclusion? I won’t be recommending them wholesale, but I might well discuss hip protectors as an option with my higher-risk patients. If anyone does decide to have them, I’ll probably recommend the soft ones.

Posted in Credits 2017, Elderly Medicine | Leave a comment

Spondyloarthritis

This is a summary of NICE guidance as per BMJ article. The spondyloarthritides are a group of inflammatory conditions with some extra-articulate manifestations. They may be peripheral or axial and are often missed.

Axial spondyloarthritis

Note that this affects similar numbers of women and men, can occur in people who are HLA-B27 negative, and does not always show up on X-ray.

Assess for axial spondyloarthritis in patients with low back pain that started before the age of 45 years and has lasted for >3 months.

Criteria to look for, in those patients:

  • Started < 35 years
  • Waking with pain in second half of the night
  • 1st degree relative with spondyloarthritis
  • Current or past enthesitis (inflammation at tendon, ligament, or joint capsule insertions – shows up as pain, protracted stiffness, and prominent swellings of large insertions – inflammatory markers may be normal)
  • Current or past arthritis
  • Current or past psoriasis
  • Improvement within 48 hours of taking NSAIDs
  • Improvement with movement
  • Buttock pain

Four or more of those criteria requires specialist referral; two or fewer is a ‘watch and wait’ with new assessment if new features develop. If a patient has exactly three, do an HLA-B27 test to tip the balance.

 

Psoriatic arthritis and peripheral spondyloarthritis

Refer if any of the criteria below:

Dactylitis (inflammation of a whole finger or toe)

Suspected new-onset inflammatory arthritis if not gout or pseudogout (urgent referral)

Enthesitis (see above) that has no apparent mechanical cause and also fits any of the following criteria:

  • Persistent
  • Multiple sites
  • Associated back pain with no apparent cause
  • Current or past uveitis or psoriasis
  • IBD
  • Gastrointestinal or genitourinary infection
  • 1st-degree relative with spondyloarthritis OR psoriasis

 

Note that, for both axial and peripheral spondyloarthritis, no single test or symptom can rule the diagnosis in or out; diagnosis is clinical and based on likelihood according to groups of symptoms/signs.

Management is 1st-line with NSAIDs and second-line with DMARDs; also specialist physiotherapy and also multidisciplinary input from specialties such as hydrotherapy and OT. Flare management may be with a mixture of exercise/stretches, and pain/fatigue management.

Posted in BMJ, Credits 2017, Rheumatology | Leave a comment