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.
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.
It seems I’ve been overdiagnosing past MIs on ECGs. A cardiologist has now sent me the helpful information that isolated Q waves in III are a variant of normal. Old inferior MI can only be diagnosed if there are Q waves in II and aVF in addition to III. Good to know!
Some interesting bits and bobs in the latest BMJ:
The three most effective NSAIDs for hip and knee osteoarthritis appear to be, in descending order, diclofenac, etoricoxib, and rofecoxib. Now, of course, that’s of limited use, given the high risk of cardiac events from both the first and third of those; but I can see it being useful in patients with a short life expectancy who are desperate for some relief from their pain.
Falls prediction scores don’t work (Minerva). In a study in A&E in Australia, the Falls Risk for Older Persons Community Setting Screening Tool and the Two-Item Screening Tool (I so want to find a way to reverse the last two words on that second one) were little better than a coin toss in predicting falls over the next six months.
It’s possible to develop abdominal pseudohernia after thoracic shingles (Minerva again) causing a lateral bulge in the abdomen due to thoracic nerve root paralysis. In the case given, this resolved spontaneously three months later, though we weren’t given figures on the likelihood of this. (The likelihood of it happening in the first place, if you’re interested, is 0.7%.)
(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)
- For bottle-fed babies, try the following:
- Reduce volumes by about 20% but increase frequency to maintain appropriate total daily amount of milk.
- 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.
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)
(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.
- 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
- 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)
- 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)
- 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
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.
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:
- 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.)
- 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).
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?)