It’s official – e-cigarettes can be recommended as a smoking cessation aid. We still don’t know for sure how safe they are, but we do know that whatever risk they might carry is a heck of a lot less than that from smoking. So, we’re not going to give e-cigarettes the green light for a non-smoker, but if they’re what you need to get you off the real carcinogen-loaded article, go for it.

Also, some practical advice for those planning to replace smoking with vaping: Vaping takes practice. There are different types (as of the time of writing this post, the most up-to-date are the third-generation devices, which are probably the best available) and also different flavours and different nicotine doses. The current advice is to persevere until you find a type, flavour and dose that feels satisfying to you (ask for advice in a vape shop, if needed) and only then plan your quit date for the regular cigarettes, although plan it to be ASAP at that point.


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Diagnosing childhood autism

This is just some rather quick notes I made on the video module ‘A practical guide to diagnosing autism in pre-school children’ on the BMJ Learning site.

Triad of symptoms for autism diagnosis:

  • Social communication
  • Social interaction
  • Social imagination

Presentation may include: Not developing language as expected, or regressing

Not responding to name

Not reciprocating

Poor eye contact – but eye contact/smiling don’t rule out autism.

More invasion of personal space than you’d expect; or discomfort with invasion of their personal space

Not happy with birthday parties/anxious over social situations

May be creative but not develop imaginative play; do they play with a variety of things, use things symbolically in non-repetitive way? Do they show signs of repetitive, stereotyped play?

Remember that you are not there to make the diagnosis; you are there to pick up concerns and refer where appropriate.

Also, from my own googling: The M-CHAT (Modified Checklist for Autism in Toddlers) is available online here.

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Primary hyperaldosteronism

I know this as Conn’s syndrome, but that’s slightly misleading; Conn’s syndrome refers specifically to an adenoma causing the hyperaldosteronism, and in fact only accounts for less than 30% of cases of PHA. PHA is important to pick up, as the long-term cardiovascular outcomes are worse than those for patients with essential hypertension (the aldosterone can directly damage the myocardium and also cause vascular remodelling).

Presentation: As well as hypertension, hypernatraemia and hypokalaemia, it can cause non-specific symptoms; muscle weakness, palpitations, and emotional lability. To confuse matters, not only may electrolytes be normal, but also the aldosterone level may be normal. (The article didn’t explain why.)

Investigations: NICE guidelines and international guidelines advise screening for PHA in the following situations:

  • Treatment-resistant hypertension
  • Severe hypertension
  • Hypertension associated with hypokalaemia
  • Hypertension in younger patients

Investigations include:

  • Aldosterone:renin ratio
  • Sodium suppression test
  • Adrenal venous sampling
  • Abdominal CT or MRI

The article didn’t go into further detail about any of those except to say that diuretics (including spironolactone) should be stopped at least four weeks before checking the aldosterone:renin ratio, to avoid false negatives.

Treatment: Surgery is the treatment of choice; laparoscopic adrenalectomy. Apparently this is low-risk (despite how it sounds) and will usually produce long-term normotension, although some patients may have underlying essential hypertension as well as the PHA and will therefore continue hypertensive post-op.

(BJGP 2017; 67: 578 – 579)

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Ménière’s disease

Frequently overdiagnosed. Presents with a combination of the following symptoms, lasting for <24 hours at a time:

  • Ear fullness
  • Fluctuating hearing loss
  • Low-pitch tinnitus
  • Vertigo episodes lasting at least 20 mins at a time (typically 2 – 3 hours).

Note that the ear fullness is frequently mistaken for Eustachian tube dysfunction, but that this can be excluded if ear examination + tympanogram are both normal; ear fullness with normal examination and tympanogram should raise suspicion of Ménière’s.

Secondary causes

The article didn’t give an exclusive list, but here are a few that struck me as important from the ones they did give:

  • Hypothyroidism
  • Tumours, especially acoustic neuromas
  • Superior semicircular canal dehiscence syndrome (SCDS) (see below)

Also the usual catch-alls – infections, metabolic or immune disorders, and genetic causes – and something called perilymphatic fistula, which wasn’t discussed further in the article.

SCDS: Increasingly recognised as an important secondary cause of Ménière’s, as it’s potentially correctable by surgery, which has a good success rate. Consists of thinning of the temporal bone over the inner ear, often to the point of actual holes in the bone. It’s now thought to have a prevalence of about 0.1% of the population, which is a lot more common than first thought.

Can present with symptoms similar to those of Ménière’s (vertigo, hearing loss and fullness in the ear) and also dizziness, nausea, headaches, fatigue, anxiety/panic attacks (which, not too surprisingly, can occur with any vestibular disorder) and cognitive impairments. It can also cause the notable symptom of autophony, which is the hearing of self-generated noises such as the heartbeat or the eyes moving.

Diagnosis is with high-resolution CT; a low threshold for this is recommended.

BJGP Dec 2017

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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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