2017 BMJs

December 2nd

Trigger finger – Occurs most commonly in men and in middle age. Particularly common in diabetics. First develops as a nodule close to the MCP joint and then triggering develops. Steroid injection (20mg depomedrone made up in 2mls 1% lignocaine) is the first line treatment. If initially successful but relapse occurs the patient can have 2 further steroid injections. Advantages – can be done in primary care and no time lost from work, Risks – depigmentation, lipoatrophy, bruising and very rarely tendon rupture. Post injection physio helps. If surgery needed this can be percutaneous (uses of a needle under local anaesthetic) or an open operation.

November 25th

Recurrent UTI in women (> 2 episodes in 12 months) – No evidence to support use of cranberry juice, urine alkalisation or probiotics. 6 to 12 months of prophylactic low dose antibiotic is most effective. Topical oestrogens help as may methenamine Hippurate (1g orally bd) or OTC oral D-mannose supplements.

Non HRT Rx of menopausal symptoms – Pharmacological – SSRI (Citalopram 10mg or 20mg), next SNRI Venlafaxine MR (37.5mg or 75mg a day), next Paroxetine (10 to 20mg but CI with tamoxifen), next Gabapentin up to 300mg tds and the last choice is Clonidine 0.1mg a day. Trial of treatment should be for one month and then change if not effective.

With regards vaginal symptoms consider topical HRT (liaise with oncologist if hx of breast cancer),silicone vaginal lubricants may be better than water based ones. For vulva soreness with sex consider 4% aqueous lignocaine a few minutes prior to sex.

No evidence, yoga, relaxation techniques or mindfulness or exercise help vaso-motor symptoms. Little evidence for use of plant phytoestrogens. Black Cohosh unlikely to help but Red Clover with a probiotic may help with flushes.

November 18th

The diabetic foot review – Look for cracked dry skin, callus, interdigital maceration, foot/toe deformity and ulcer. Feel with dorsum of hand for temperature. Feel for pedal pulses. 10g monofilament test at 10 sites (plantar aspect - great toe/middle to/ little toe, fifth/third/first metatarsal heads/ medial and lateral mid foot, heel and ONE dorsal site). If at any one of those sites sensation is reduced – check 3 times – foot at risk if neuropathy at any one site confirmed. Presence of PAD (any absent pulse) or Neuropathy or foot deformity = medium risk. Presence of two or more or active ulceration = high risk. Medium risk – review 6 monthly. High risk 2 monthly. All should have foot care advice.

November 4th

Approaching psychotic symptoms (useful questions) – Adopt a non judgemental attitude however bizarre their version of reality may be. Avoid arguing with the patient regards their symptoms e.g. “I understand that this may be how it appears to you but this is how it appears yo me ….”. Other useful questions include: It seems that you have a lot on your mind, what are the most worrying thoughts that you have been having? Have you been feeling that people are talking about you, watching you or giving you a hard time for no reason? Have you ever felt that your thoughts have been controlled by another person? Have you been seeing or hearing things that other cannot? Have you been spending more time alone?

November 4th

Allergic eye disease – Usually bilateral and itching arethe hallmarks of allergic eye disease. It is a type 1 hypersensitivity response. Seasonal is triggered by pollens and perennial by exposure to environmental allergens such as house dust mite, fungal spores etc. Use cold compresses and regular eye lubricants. If seasonal avoid allergen exposure – sunglasses, car windows closed, AC on and avoid rubbing etc. Use topical antihistamines e.g. Ketotifen or Azelastine +/- mast cell stabilisers e.g. Cromoglycate or Nedocromil +/_oral antihistamine. For short term relief of severe acute symptoms consider topical vasoconstrictors which can be bought OTC e.g. xylometazoline and the preparations often contain an antihistamine. Specialist may use tacrolimus, steroids, ciclosporin for refractory cases.

October 28th

Cystic Fibrosis – 16% of patients with CF are diagnosed over the age of 16 due to CF mutations which are not as severe. Consider in patients with recurrent chest infections, bronchiectasis, pancreatitis, malnutrition/malabsorption, osteoporosis, liver disease or azoospermia.

October 21st

Post hip/knee replacement – NSAIDS may inhibit bone healing so should be avoided if possible after hip and knee replacement, especially if they are cementless prostheses, as they rely on osseous integration. Paracetamol and codeine are the analgesics of choice.

Paediatric hernia – Umbilical hernias are common, most will resolve by the age of four years. Refer if still present after 4 years. Incarceration is uncommon but parents need to be aware of S&S and necessary actions.
Epigastric hernias usually contain peritoneal fat. They do not strangulate. One third are irreducible. All should be referred.
Inguinal hernias are more common on the right than left 7:1. All need referral. Incarceration is a real risk, especially for pre-term infants during their first year of life. An inguinal hernia on one side increases the risk of a contralateral inguinal hernia developing later on the other side.

Oct 14th

Insulin pumps – In children use of insulin pumps, rather than basal bolus regimes, has considerable less risk of hypoglycaemia, DKA and provides better glycaemic control.

Oct 7th

Antiplatlets with anticoagulants – Increased annual risks of bleeding – 4% when used in isolation rising to 15% when triple therapy used (aspirin, clopidogrel and warfarin). What to do when both antiplatelets and anticoagulation are indicated.

  1. Secondary prevention of CVD – in chronic stable CVD prescribe oral anticoagulant therapy in isolation. In patients at high risk of recurrent events prescribe aspirin and anticoagulant. Post stent triple therapy is used but Py2 inhibitors are stopped usually within 6 months, then dual therapy up to 12 months. At 12 months, if CVD is stable consider switch to monotherapy.
  2. Valvular heart disease – aspirin may be of benefit when prescribed with warfarin for patients with mechanical prostheses.
  3. VTE – DVT needs anticoagulation for a minimum of 3 months, consider aspirin cessation if they have chronic stable CVD during this period and then re-start.
  4. Aspirin is preferential to PY2 inhibitors (clopidogrel etc) when used with warfarin (unless triple therapy is indicated)
  5. Consider co-prescribing H2 blocker or PPI to reduce GI bleed risk
  6. Patients need annual review (use HAS-BLED) to establish risk/benefits of continued dual therapy.

September 23rd

Steroids and sore throats – A single dose od 10mg dexamethasone in adults or 0.6mg/kg in children may increase the chance of resolution of pain within 24 and 48 hours and reduce the severity of pain.

September 16th

HRT- WHI study long term follow up – no excess CVD deaths, cancer deaths or all cause mortality in the women using hrt from the 5.6 year or 7.2 year cohorts.

Diabetes in remission – Remission of diabetes through weight loss is attainable for some patients. Usually they need to lose 15kg or more. Doctors often forget to discuss this as an option. Diabetes in remission is confirmed by 2 Hba1cs, separated by at least two months, below the diagnostic threshold. They can be considered non-diabetic for insurance purposes. The patient needs Read coding as diabetes in remission and to have annual Hba1c to ensure that they have slipped back into diabetes and will still need annual retinal reviews.

September 9th

Endometriosis – Effects 10% of women of reproductive age. Diagnosis is often late, reducing quality of life and leading to disease progression. The diagnosis in young women is often missed and it may effect women in their late teens. Consider the diagnosis if they have chronic pelvic pain, dysmenorrhoea impacting on quality or life or deep pain during or after sex. Also, period related cyclical urinary or GI symptoms may be due to endometriosis. Offer pelvic and abdominal exam. USS is usually negative although transvaginal ultrasound is better than abdominal USS. Also CA125 may be raised. Try up to three months of NSAIDS and/or the COCP or neuromodulators. If these measures fail consider referral. If patients have symptoms suggestive of bowel or bladder involvement refer straightaway to a specialist endometriosis centre.

September 2nd

Opiod induced constipation – effects over half of patents on opiods, especially in palliative care. They reduce co-ordinated peristalsis and GI secretions. Encourage fluids and where possible exercise and higher fibre diet. Start a stimulant laxative, such as Senna or Bisacodyl when initiating an opiod. If that fails add a stool softener such as Docusate or osmotic laxative such as Movicol. Provide advice on the best position to pass stool (knees higher than hips, leaning forward with elbows on knees and straight back - a squatting like position relaxes puborectalis). If that fails then consider switching to a less constipating opiods, such as Buprenorphine or transdermal Fentanyl. If that fails or is not an option then add u-opiod receptor antagonist e.g. Naloxegol oxalate (oral) or Methylnaltrexone (SC) which negate the constipating effect of opids but not their analgesic effects.

August 26th

Chronic vertigo - Each year around 1 in 20 people experiences vertigo. Most cases are caused by peripheral vestibular disorders such as vestibular neuronitis, benign paroxysmal positional vertigo, vestibular migraine, and Ménière’s disease.

All peripheral vestibular disorders have a distinct natural course with a substantial chance of developing chronic vertigo: 30-40% of patients with vestibular neuronitis still experience vertigo after six months, and 50% of patients will have experienced recurrence of benign paroxysmal positional vertigo by 3-5 years after initial diagnosis.

Peripheral vestibular disorders induce an innate repair mechanism known as vestibular compensation. Chronic vertigo occurs when natural vestibular compensation fails. Vestibular re-hab exercises are the treatment of choice not vestibular sedatives. See

August 5th 12th (double publication)

Parkinson’s Disease – Dopaminergic therapy is associated with an increased risk of Impulsive Control Disorders. This is not just limited to compulsive gambling but also includes binge eating, hypersexuality and obsessive shopping. Patients may conceal their ICDs from family, friends and doctors.

Management of non-motor symptoms; excessive day time sleepiness (modafinil), REM sleep disorder (clonazepam or melatonin), orthostatic hypotension (midodrine 1st line and fludrocortisone 2nd line), hallucinations or delusions (quetiapine) or drooling (gycopyrronium bromide).

July 29th

Inflammatory arthritis – DMARD therapy commenced within 3 months of onset of symptoms improves function, reduce long term joint damage and long term disability. Patients suspected of inflammatory arthritis warrant urgent referral. Early use of combinations of DMARDS and escalation of treatment to control inflammation (treating to target) produces the best outcomes. DMARDs take 8 to 12 weeks to work. Remission can now be achieved in 65% of patients using this strategy.

Flares can occur and any time and most patients will have a flare within a 3 year period. GPs can use im depomedrone to provide symptom relief pending prompt review by rheumatology regards possible DMARD up titration.

Palpitations – 1/3 of patients referred with palpitations have an arrhythmia. 2/3 have ectopics or increased awareness of sinus rhythm. Holter monitors can be used for 24 and 48 hours monitoring. Specialists have access to external loop recorders which can monitor from 1 to 4 weeks. Also, a number of smart phone apps can be downloaded which have been shown to be accurate (but have a cost to the patient) e.g. AliveCor Heart Monitor smartphone app. They have the advantage of being used at any time the patient has symptoms.

July 22nd

Post PCI for STEMI – After uncomplicated PCI for STEMI, most patients are sent home after three days.They should be on 4 classes of drugs; Dual antiplatelet therapy (12 months then aspirin alone), a Betablocker, an ACE and a Statin. Antiplatelet therapy is not a CI to oral anticoagulation, if it is required for other conditions. If no planned further re-vascularisation and ejection fraction > 40% they can fly after one week and drive their car after 4 weeks. For HGV and Bus drivers they have to have the above and a normal stress test at six weeks. If able to walk up two flights of stairs without symptoms then sexual activity can re-start after 1 week. 60% of men suffer ED, it is not related to Betablocker use. Viagra like drugs can be used if they are not taking a nitrate and do not require prn SL GTN.

Smoking cessation reduces all cause mortality by 1/3. A Mediterranean diet is recommended, as it exercise for 30 minutes five to seven days a week. Don’t forget 999 rules and flu vac/penumovac.

July 15th

ADHD stimulant medication – Used in combination with behavioural and psychological interventions. It works by increasing extracellular dopamine at the synapses. Reduces symptoms and improves quality of life and improve academic performance. Effective in both childhood and adulthood. Patients with troubling ADHD symptoms should continue treatment into adulthood. Different preparations are available – 8 v 12hr duration. Side effects are usually minor. They may include dry mouth, reduced appetite, disturbed sleep and rarely reduced growth, raised pulse and BP. They are contra indicated in schizophrenia, hyperthyroidism, angina and glaucoma. Monitoring involves P, BP and Height check, as well as reviewing side effects and consideration of a trial of stopping treatment.

July 8th

Hep C Viral infection – Only symptomatic in the acute phase for 1/3 of patients (arthralgia, fatigue and or jaundice). Just under half of young patients will clear the virus spontaneously. Those that don’t develop chronic infection and progressive liver damage. It takes several weeks for HCV antibodies to develop and should be repeated if negative at 12 weeks. Refer ‘all’ patients. The goal of treatment is to eradicate the virus. Direct oral antiviral drugs have replaced interferon therapy.

Chronic Hep C may present with non-hepatic manifestations; Rheumatological (myalgia, fatigue, arthritis and Sjogren’s syndrome), Dermatological (cutanea tarda and lichen planus) and Haematological (cryoglobulinaemia causing arthritis, fatigue and neuropathy).

July 1st

Gender dysphoria – Explore how long the patient has had these feelings and if they have disclosed them to their family, friends or trusted work colleagues. Show empathy and explain their experiences are not uncommon. Patients often fear being judged or their feelings dismissed. Explore what steps, if any, they have taken. Have they changed their name, does their clinical record need amending? Specifically ask if they have been using hormones, as they may be using non-prescribed drugs and determine the nature of the drugs and their dosages. There are an array of informal support services, consider signposting the patient to

Explain they need referral to gender services but there is often a 9 to 15 month waiting list for gender identity clinics. These clinics have a MDT approach (counsellors, psychologists, speech therapists, endocrinologists and physicians). Hormone therapy and surgery is available on the NHS but not ENT surgery, facial surgery or augmentation mammoplasty. Always consider birth gender regards on-going screening services (Cx screening, AAA screening etc).

June 24th

HPV vaccination – Offered to all girls (12-13years) at school. IM injection at 0 and 6 months but if over 15 years old they need three doses at 0, 2 and 6 months. Not used in over 18s. Very effective in preventing HPV type 16 & 18 related precancerous cervical change AND also very effective in preventing ano-genital warts. Note it does not protects against the 30% of Cx cancers which are caused by HPV subtypes not in the vaccine, so enrolment in the smear programme is essential.

June 17th

Stress at work – Common causes to explore include; Bullying, humiliation, harassment, work overload, lack of support, isolation, conflict of values. Important questions to ask include; nature of their work, causation of their stress, chronology of events, screen for depression, ask re drug and alcohol misuse, exercise and explore family and social support.

Treatment – Little quality evidence exists. Usually consider; time off or amended duties, on line or face to face stress management courses, advising they speak with their line manager, increasing exercise, decreasing alcohol, liaison with occupational health and union rep if available. Follow up appointment to review progress.

June 10th

Bullous Pemphigoid & Pemphigus – Pemphigus is the commoner type, usually effects 40 to 60 year olds. Patients often develop painful swallowing, sore throat or even hoarseness as oral lesions develop before skin changes. Flaccid easily rupturing blisters/red lesions form on the back, chest and scalp. Localised disease can be treated with potent topical steroids. More generalised disease requires oral steroids. Immunosuppressants are also often used.

Pemphigoid is rare and usually effects people over 80. Usually starts with highly pruritic lesions which become tense fluid filled blisters. requires oral steroids. Doxycycline is an alternative to oral steroids. Immunosuppressants are also used as a second line agent.

June 3rd

DVT in pregnancy – Commonly presents with lower extremity discomfort and oedema. The Wells score is not validated for pregnancy. D-dimers are often raised in normal pregnancy. The diagnostic test of choice is compression ultrasonography. Low molecular weight heparin is the treatment of choice and is continued for 6 weeks post-partum and for a minimum duration of 3 months. It is stopped at the first sign of labour and started after delivery. In planned delivery a switch to iv heparin can be used prior to delivery.