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

Acute rotator cuff tears

A possible complication of acute shoulder trauma. Unlike chronic tears, an acute tear needs fairly urgent repair but is easily missed.

  • If a person cannot lift their arm past 90 deg following acute shoulder trauma, they need same-day X-ray and review.
  • If a person cannot lift their arm past 90 deg two weeks later, they need urgent referral for assessment by either ultrasound or MRI (MRI has greater sensitivity, but both are good).
  • Shoulder dislocations in the >40s should also be followed up for possible acute rotator cuff tear.

(BMJ 2017;359:j5366)

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Ear conditions

Exostoses: overgrowths of bone in the external ear canal; they present as whitish lumps narrowing the canal. They are particularly common in people who spend a lot of time swimming in cold water. They can obstruct wax or cause hearing loss, and can be surgically removed if they become a problem, which is the exception rather than the rule. They can be distinguished from aural polyps (red and fleshy) and osteomata (benign bone tumours of skull sutures within inner ear – usually pedunculated and single).

Foreign bodies in ear: Referral for removal at some point in next seven days is fine, unless it’s a button battery, in which case the FB needs removing urgently.

Cholesteatoma: Presents with scanty recurrent or persistent offensive cream-coloured discharge and progressive hearing loss. Examination typically shows pearly-white mass (usually in pars tensa) and/or crust. May look similar to OM. Note that a crust adherent to the tympanic membrane is cholesteatoma till proved otherwise (though it may be possible to try a short course of steroid drops or drops for wax first, then review).

While waiting for ENT appointment for cholesteatoma, keep the ear dry and, if signs of infection, try 2/52 antibiotic drops, with or without steroids.

Cholesteatoma surgery leaves a mastoid cavity. This can be prone to discharge/wax buildup; if it becomes problematic, further surgery can be done to obliterate it.

Retraction pockets vs. perforations: They look similar, but the edge of a perforation will be more clearly delineated and the membrane will be visible over the structures behind (‘shrink-wrapped’ look).

Neither needs referral unless causing problems. With perforations, the ear must be kept dry. Note that clean traumatic perforations will mostly heal within 6 – 8 weeks.

Otitis media with effusion: In >90% of cases will resolve spontaneously within three months, so hold off on ENT referral until then if symptoms not a big problem. However, in the case of children, do refer to paediatric audiology in meantime to assess hearing, and do advise parents about possibility of hearing loss and about managing this by speaking clearly, having time to talk to child with no competing sounds, letting child sit at front of groups to see the speaker, etc.

Blocked grommet: Prescribe sodium bicarbonate ear drops, review, normally arrange hearing test to see how much of a problem there is.

Fungal otitis externa: Causes itching, otorrhoea, greyish-white creamy mucopurulent exudate, disproportionate pain. On examination, the exudate is visible plus a localised white fluffy patch of fungal mycelia. Can often be triggered by moisture or by topical antibiotic drops (especially neomycin).

Bullous myringitis: Blisters on the inside of the tympanic membrane, caused by viral or bacterial infections. Can cause serosanguinous discharge. Easily confused with Ramsay-Hunt syndrome, but in the latter the blisters are multiple and smaller.

Treat with antibiotics (ideally Amoxicillin) and review in a week – refer to ENT if not resolving.

(BMJ Learning: Tympanic membrane diagnostic picture tests and more tympanic membrane diagnostic picture tests.)


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BP control before surgery

A reference in the latest BJGP has just answered a question I’ve been meaning to look into; how good a blood pressure control do we need to aim for in patients we’re referring for surgery? Not as strict as I’d thought; according to joint guidelines from the Association of Anaesthetists from Great Britain and Ireland and the British Hypertension Society, we can refer as long as the average blood pressure over the past year has been <160/100 mmHg. Also, if a patient with a blood pressure above this refuses to take more medication or if it proves impossible to get their blood pressure under better control, we can apparently take a ‘quantum in nos fuit’ attitude and refer them anyway.

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Steroids for sore throats

An update on this problem: a systematic review and meta-analysis in the BMJ. This found that there is, in fact, moderate quality evidence that a one-off dose of steroid can improve pain in sore throat. Not the speed with which a patient can get back to work or school; just pain.

The article described this as ‘low dose’, but in fact most of the doses in the adult studies were 10 mg dexamethasone (in one case given as 5 mg on each of two days), which equates with around 62.5 mg of prednisolone. One study did try prednisolone, at a 60 mg dose. In children, the doses given were 0.6 mg/kg of dexamethasone up to a maximum of 10 mg total. Not really sounding like that low a dose to me. No sign of any harms, but I’d still be nervous about giving that kind of a dose (maybe over the two days? 30 mg of Pred on two days?) plus a linked commentary points out that it didn’t look at cumulative effect of having a lot of sore throats and a lot of steroids for them.

(BMJ 2017:358:437)

Posted in Credits 2017, Medication, Minor but annoying | Leave a comment

Shingles infectivity

After having a case of shingles and two more suspected cases (which turned out not to be) at the care home where I work, I thought it might be useful to put together a protocol for staff. I posted this to the Doctors.net.uk forum to check I hadn’t made any egregious errors, and the question was raised of whether I was giving them the correct advice on infectivity. I’d assumed it was the same as for chicken pox, but in fact, although the same virus is involved, a person with shingles is rather less likely to pass it on. But how likely, and what precautions do we need to take? This turned out to be more complicated than I’d anticipated.

Firstly, there seems to be no doubt that being in contact with the rash is a risk, as you might expect. The virus can also persist on bed linen, towels, and washcloths. This has obvious implications for staff, and one of the issues I had to consider was whether to request that all staff be asked to have routine varicella testing as part of employment. That way, we would know which staff could safely work with residents that have shingles.

The question, however, is what risk is involved in being in the same room as someone with shingles whose rash is covered. In other words, is droplet transmission a factor?

Accepted wisdom says no (unless the person with shingles is immunosuppressed). However, when I raised the question on DNUK, one helpful person found me some links, including this useful summary of evidence on Medscape. One particularly notable case history cited by that article was of a healthy, immunocompetent patient in hospital with shingles; PCR on swabs taken from various places in the room, including an air filter which the patient hadn’t touched, confirmed that she was, in fact, breathing out VZV. But how much? That study can’t give us quantitative accounts.

The article also cited some interesting-sounding Russian studies; one that quantified the amount of virus spread by patients with shingles as being a quarter of that spread by patients with chicken pox, one that confirmed cases of chicken pox occuring as spread from shingles, and, most annoyingly tantalising of all, one that had apparently followed over two thousand patients over a ten-year period, figured out the degree to which droplet spread and chicken pox infection were an issue, and, from this, come up with what sounded like exactly the sort of detailed instructions I was looking for, available to anyone who could not only get hold of the article in question but who could read Russian. So, that’s helpful, then.

The only thing I could find on Public Health England was a guideline for inmates in prison or other places of detention; this advised that viral spread from shingles can occur ‘if the lesion is on an exposed site and there is direct contact with a susceptible person’ and that a significant contact would be ‘direct contact with a shingles rash on an exposed part of the body when the lesions have not yet crusted over’ which would seem to imply that droplet spread isn’t an issue. However, the guideline then goes on to advise isolation for affected detainees without differentiating between chicken pox and shingles, so that’s a little unclear.

The CDC guidelines advise avoiding people in specific high-risk categories; namely, pregnant women, premature or LBW babies, and the immunosuppressed. The implication there, although not stated, seems to be that you don’t have to avoid people in other categories as long as the rash is covered.

I think the bottom line is that no-one knows for sure. (Apart from some people in Russia.) So, it is in effect a matter of balancing a theoretical low risk of infection against the known harm to a care home resident of having to stay in isolation when they want to be out and doing things (plus, I might add, the difficulty of enforcing this in the case of some of our demented patients). My inclination, after reading all this, was not to order isolation for shingles patients.

I contacted the local microbiology team, from where the consultant advised me that this was correct as long as the rash could be covered, but that patients with an uncovered rash should be isolated. This seems a fair compromise. She also agreed that it would be advisable for all care home staff to have their immunity to varicella checked, but advised that this needed to be the decision of the home’s occupational health department and that I should contact them.

Armed with that information, I shall complete the protocol and send it to the care home, and I’ve raised the issue of immunity testing with the care home manager as something to pass on to their OH department; she agreed this was a good idea.


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Secondary post-partum haemorrhage

Blood loss of >500 ml for a vaginal birth or >1000 ml for a CS, between 24 hours and 12 weeks postpartum.

Causes: Retained products or endometritis.

Examination: Note that the uterus should not be palpable abdominally by day 14; if it is, it suggests one of the above diagnoses. Check also for uterine tenderness and offensive vaginal discharge.

Management: Ultrasound scan/obstetrics review for RPOC. I guess they’ll sort out antibiotics if needed; in any case, the article doesn’t specify which ones are recommended, just saying ‘broad-spectrum’.

A final note is that, although I obviously won’t be dealing with primary post-partum haemorrhage, women who’ve had PPH should have FBC/ferritin as part of their post-partum follow-up, so that’s worth remembering from my point of view.

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Contraception in the perimenopause

DMPA and Sayana Press do cause decrease in bone density, but this is reversible and thus not considered an absolute contradiction to contraception over 45. Review every two years for other risk factors is advised. The FSRH do advise against using it over 50.

Progestagen-only methods, because of the irregular bleeding patterns they induce, do lead to a higher rate of investigations when used in the over-45s.

Hypertension and DVT history are not considered contraindications to POC. Current breast cancer is (it’s the only thing that’s a UKMEC 4 for all methods of POC) but there is no evidence that POC use increases breast cancer rates.

FSH levels are helpful in diagnosing premature menopause, but not helpful in women >45 with perimenopausal symptoms – at that point, it’s better just to diagnose menopause clinically.

Menopause = date of cessation of periods. Diagnosed in retrospect one year later (although the two-year rule for fertility cessation under 50 still applies). Perimenopause = the period of time from onset of symptoms to one year after the menopause.

When CHC is used for women over 40 years, expert advice is to go for <30 mcg EE as first choice.

Options for combining contraception and HRT

  • Combined hormonal contraception alone (if no CI). Note that FSRH advise against this in over-50s.
  • IUS + oestrogen replacement
  • POC + combined HRT

Stopping contraception

In a woman having periods, the rule is still ‘two years after LMP if under 50, one year after LMP if 50 or over’. The ‘under or over 50’ applies to the LMP date, so if a woman over 50 had her last period under 50, she still has to wait two years.

In an amenorrhoeic woman on POC, continue contraception until at least 50. After that, the rule is to measure FSH of 30 or greater on two occasions six weeks apart, then wait one further year before stopping.

The FSRH recommends that contraception can be stopped safely at 55 years unless a woman is still having regular periods at that age. However, some experts now question this and say that natural fertility loss can only be assumed at 60 years. (Of note: the oldest recorded age of a woman becoming spontaneously pregnant in the UK is 57.)

(BMJ Learning module – Contraception in the perimenopause

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