Shortening PFIs

Remember that some of the newer pills are designed to have shorter PFIs (known a little more accurately as HFIs; hormone-free intervals) by having more actual pills per packet – that way, it’s possible to shorten the PFI without also giving yourself more frequent PFIs per year. The current pills on the market that do this are:

2 day PFI: Qlaira (estradiol valerate + dienogest). Note that this is a quadraphasic pill and so cannot be tricycled.

4 day PFI: Zoely (estradiol + nomegestrol) and Eloine or Daylette (EE + drospirenone)

Obviously, Qlaira has 26 pills per pack and Zoely, Eloine and Daylette have 24.

(BMJ Learning module – Contraception and the perimenopause)

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Dermatology revision

For the record, just went through this slideshow on emedicine. No particular notes, but very good practice to actually look at examples of the rashes now and again.

Posted in Credits 2017, Dermatology | Leave a comment

Management of paediatric hernia

BMJ review article:

Umbilical hernias: Usually close spontaneously by the age of 4, and can be safely left to do so as complications are rare. However, spontaneous closure becomes less likely in children over 4, so if a hernia hasn’t closed by then then it’s worth referring the child to surgery.

Epigastric hernias: Not dangerous (no known reports of them leading to strangulation), but don’t resolve spontaneously, so should be routinely referred.

Note that epigastric hernias a) can have multiple defects, and b) should not be confused with divarification of the recti, which presents as a uniform midline bulge when the supine patient raises head, and resolves as abdominal wall musculature develops.

Inguinal hernias: High risk of complications; refer. Incarceration risk does go down with age, so older children with asymptomatic hernias can be referred more routinely.

Note risk of contralateral hernia (which may develop after first hernia operated on).

Note that almost all incarcerated hernias can be successfully reduced, but 15% will re-incarcerate within the next five days, so discuss urgently with surgical team.

May be repaired by either open or laparoscopic surgery; jury’s out on which is better.

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

Arthroplasties – the post-op period

This BMJ article covers post-op management of shoulder, hip, or knee arthroplasty. A lot of this is obviously going to be managed by the surgical team in question, but there are invariably GP queries, so I thought it was worth making some notes.

Analgesia: Avoid NSAIDs where possible; they may interfere with bone healing. One study shows that patients who took Ibuprofen for post-op analgesia following a THR had higher rates of revision in the next ten years than patients who didn’t.

Patients are likely to need weak opiates + paracetamol for the first four to six weeks post-operatively. If pain is ongoing thereafter – especially at night – it should be investigated for malpositioning or infection; check inflammatory markers and X-ray and get orthopaedic review.

Wound ooze: Has normally ceased by the third or fourth day post-operatively, although may take longer in patients with diabetes, patients on anticoagulation, or obese patients. If a wound is still oozing slightly by day 10, that may indicate infection; get them reviewed by their surgeon. The same applies to slightly dehisced wounds.

Sutures: Wounds should have healed enough to remove sutures by 10 days. If an absorbable suture was used, it will often leave tags at either edge of the wound; these can be cut after 10 – 16 days.

Dressings: Keep the wound covered until the scar is fully healed and the sutures removed.

Suspected infection: Do not treat empirically even if you think the infection appears superficial; it’s very difficult to tell for sure, and patients with suspected infection post-arthroplasty need to be referred back to their surgeons for consideration of joint aspiration.

VTE prophylaxis: NICE recommends 4 to 5 weeks for THR and 10 to 14 days after TKR.

Physiotherapy: I assumed post-op physio was important for getting the joint functional in the short term, but it seems it’s a lot more even than that; post-op physio and rehabilitation (which should continue for approximately 13 weeks post-op) is extremely important for long-term function and for avoidance of complications.

Driving: Most organisations recommend avoiding driving for at least six weeks after any joint replacement. As always, patients should only restart when they can do an emergency stop.

Restrictions on movement: Are important to avoid post-op dislocation.

After TKR: Avoid kneeling or sitting cross-legged, especially for the first six weeks.

After shoulder replacement: Keep the arm in a sling for the first six weeks and avoid resisted internal rotation (shutting doors, pulling cord of blind), putting arm behind back, or letting arm fall to rest from beyond back. Avoid heavy lifting for six months.

After THR: Things get more complicated. Certain movements (flexion, adduction, internal rotation) are known to increase the risk of dislocation and are advised against, as hip dislocation post-op leads to dangerous pressure on the sciatic nerve. However, avoidance those movements in the post-op period has been shown to lead to reduced function. The article recommends avoiding these movements but advises going with the advice of the surgeon.

Longer-term restrictions: Some activities are more likely to lead to wear and loosening of the implant with a risk of earlier need of revision. Activities to try to avoid long-term include:

Hip or knee:

  • Running or impact exercises
  • Twisting sports or jobs
  • Contact sports

Shoulder:

  • Sports requiring throwing motions (e.g. tennis)
  • Hammering or other activities with similar moves
  • Contact sports
  • Other actitvities that increase the risk of falling onto outstretched arms.

Swimming is good exercise for anyone following a joint replacement. Cycling and walking should also be promoted following shoulder arthroplasty, and gentle walking and dancing following hip or knee arthroplasty.

Air travel: Carries a risk post-op, especially with long haul flights or with multiple flights in a short time. There’s also a risk of activating security alarms in the airport.

 

Posted in Credits 2017, Joints, Orthopaedics | Leave a comment

Antiplatelet therapy with anticoagulation therapy?

A BMJ article addressing an important and common question; in patients who have an indication for antiplatelet therapy plus an indication for anticoagulant therapy, should we give both or just one?

In most cases, we should just give the anticoagulant, according to this article. (In the case of DVT, where the need is temporary, remember to switch back to antiplatelet therapy when the anticoagulant is stopped.) So, for the typical situation of IHD + AF, just anticoagulation is enough.

The exception is when someone is at particularly high risk for coronary events, when you go for dual therapy (the antiplatelet therapy in this case could be either aspirin or clopidogrel). Particular examples include treatment after ACS or PCI, when it’s generally recommended that patients have triple therapy for the initial phase (which may be from four weeks to six months) followed by dual therapy until 12 months post event.

When a patient is having dual therapy, aspirin is normally the antiplatelet therapy recommended as first choice, unless there’s a reason why it can’t be used. If the anticoagulant is a DOAC, use the lower licenced dose. Remember to consider PPI cover and to check for concomitant oral NSAIDs or other medications that might increase bleeding risk.

As with so many things, there’s a huge ‘no-one really knows’ factor; these recommendations are primarily based on expert opinion plus extrapolation from non-randomised data. As always, weigh up risks and benefits; remember CHA2DS2VASc and HASBLED.

Posted in Anticoagulants, Cardiovascular, Credits 2017, Haematology, Medication | Leave a comment

Sports hernia

Yet another one (pretty much the last, for now) from the archives. This article comes from the BJGP of March 2013.

‘Sports hernia’ – also known as sportsman’s hernia, athletic pubalgia, and Gilmore’s groin – is not, in fact, a hernia. It’s a weakness of the posterior wall of the inguinal canal, caused by a set of injuries to the abdominal and pelvic musculature outside the hip joint.

Epidemiology: The typical patient is a young male who actively participates in sport, especially football, hockey or athletics. It’s considerably less common in women and in people who don’t participate in sport (although it can affect both these categories) and is rare in children and older people.

Presentation:

  • Dull, poorly localised groin pain
  • Caused by exertion but can persist for days or weeks following exertion
  • Above the inguinal ligament and radiating towards the scrotum/inner thigh
  • Can cross the midline or be bilateral in nature
  • Absent or mostly so when patient resting from sport; recurs when they take the sport up again
  • Often insidious onset

Examination:

  • Tenderness over pubic symphysis and/or pubic tubercle
  • Exquisite tenderness when the superficial inguinal ring is directly palpated via scrotal inversion with the little finger
  • The ‘direct stress test’ – palpation over the superficial inguinal ring is uncomfortable while the patient is lying supine but pain is increased (and similar to presenting complaint) when the patient straight-leg raises while palpation continues.
  • Resisted sit-ups are painful.

Investigation: Ultrasound or MRI are useful both in helping with the diagnosis and assisting with other pathologies.

Treatment: Start with conservative management for 6 – 12 weeks. This includes rest, NSAIDs, steroid injections and physio. A patient who is pain-free following this should attempt to return to sport.

If this isn’t successful (more often than not it isn’t), move on to surgical management, which consists of reinforcement of the posterior abdominal wall either by open or laparoscopic surgery, followed up by physio. Normally patients can return to full activity between 6 and 12 weeks. Surgery is successful in over 90% of cases.

Plan: If suspicion of a sports hernia is high based on history and examination, start with conservative management. If there is diagnostic uncertainty, arrange scan as above. If symptoms persist and are impacting on the patient’s quality of life, the patient is suitable for surgery, and other causes of groin pain have been ruled out, or if there is diagnostic uncertainty, then refer to a general surgeon with a particular interest in sports hernias.

Posted in Credits 2017, Orthopaedics, Sports medicine | Leave a comment

Remission of diabetes?

I’ve often wondered what happens if a diabetic person actually makes significant enough lifestyle changes to bring their blood glucose down into the non-diabetic range; since diabetes is diagnosed based on glucose levels, would this mean that this person had ‘cured’ their own diabetes? Pretty much, it seems, according to the official ADA guidelines on the subject. According to these, if a person with diabetes can manage all of these criteria:

  • HbA1c < 48 mmol/mol
  • Fasting blood glucose <6.9
  • without medication
  • maintained for one year

then that counts as partial remission if bloods are still in the prediabetic range, and complete remission if they’re below that.

Which, of course, brings up some questions. Should these people still be followed up? And the perennial question – how to code this?

That’s what this BMJ article is about. There are no current data on outcomes for people who fall into this category, probably because there are so few of them (and, as the article points out, many of the ones who exist are overlooked when it comes to coding). The article advises continuing annual testing.

For coding, the correct Read code is C10P – ‘diabetes in remission’. This means that they can be considered non-diabetic for purposes of driving or insurance, but they still get their annual reviews and retinal screening.

This code, by the way, is not to be confused with 21263 or 212H, both of which are for ‘diabetes resolved’. This refers to secondary diabetes that resolved after the cause (such as steroid treatment) was removed. Interestingly, the authors also state that it applies to patients who were misdiagnosed with diabetes, which seems wrong to me; ‘diabetes resolved’ is not the same thing as ‘never actually had diabetes in the first place’. In any case, patients with ‘diabetes resolved’ do not need annual follow-up.

Posted in Credits 2017, Diabetes, Endocrinology | Leave a comment