Abstract
Acute chest pain
The National Institute for Health and Care Excellence (NICE) guidelines on acute chest pain have been updated recently. The guidance on how to manage patients with stable angina has been formalised. Any patient with acute current chest pain, or having had chest pain in the last 12 hours, should be referred to hospital as an emergency. Patients who have had chest pain in the last 72 hours, but not within the last 12 hours, should be referred on the same day. This may be important medico-legally as it supports a decision not to refer patients when symptoms do not suggest angina. It is important to include your assessment of the type and nature of chest pain in any referral to secondary care colleagues. Another key point in the guidance is that computed tomography (CT) angiography is the next best test if coronary disease cannot be excluded. If no significant coronary artery disease is found, then other causes for these symptoms should be considered.
NICE. (2016). Chest pain of recent onset assessment and diagnosis. Retrieved from www.nice.org.uk/guidance/cg95
Loneliness
A recent report has predicted that loneliness will reach epidemic proportions by 2030 unless action is taken. The government has appointed the first minister for loneliness. A meta-analysis of over 140 studies found that social isolation, loneliness or living alone had a significant effect on the risk of premature death; equal to the risk of death from obesity and smoking. The meta-analytic review also found that results differ across the age of the patient, with those younger than 65 years old being more likely to have social deficits associated with death. It is thought that people who are lonely and isolated have poorer health behaviours, including smoking, physical inactivity and sleep disturbance.
Holt-Lunstad, J., Smith, T., Baker, M., Harris, T., & Stephenson, D. (2015). Loneliness and social isolation as risk factors for mortality: A meta-analytic review. Perspectives on Psychological Science, 10, 227–237. doi: 10.1177/1745691614568352.
Breastfeeding
A 30-year study following women who breastfed their children has found protective effects for both mothers and their children, showing that we should be supporting women to breast feed their child for as long as possible. The study found that women who breastfed for 6 months or more had a 47% reduction in their risk of developing type II diabetes compared with those who did not breastfeed at all. Women who breastfed for 6 months or less had a 25% reduction in diabetes risk. The long-term benefits of breastfeeding on lower diabetes risk were similar for women from all ethnicities.
Gunderson, E., Lewis, C., Lin, Y., Sorel, M., Gross, M., Sidney, S.,…, Quesenberry, C. (2018). Lactation duration and progression to diabetes in women across the childbearing years. Journal of the American Medical Association Internal Medicine, 178(3), 328–337. doi: 10.1001/jamainternmed.2017.7978.
Turmeric
Encourage patients to eat curry! A recent double-blind placebo controlled trial has found that curcumin (turmeric, the yellow spice in Indian dishes) can help to improve memory and attention. The 18-month study found that the people taking curcumin had mild improvements in their mood and on brain positron emmission tomography (PET) scans. The mechanism is unknown, but a reduction in brain inflammation is postulated.
Small, G., Siddarth, P., Li, Z., Miller, K., Ercoli, L., Emerson, N.,…, Barrio, J. R. (2018). Memory and brain amyloid and tau effects of a bioavailable form of curcumin in non-demented adults: A double-blind, placebo-controlled 18-month trial. The American Journal of Geriatric Psychiatry, 26(3), 266–277. doi: 10.1016/j.jagp.2017.10.010.
Asthma diagnosis
One of the proposed diagnostic tests for asthma is fractional inhaled nitrous oxide. Theoretically, use of specific tests will reduce the prescription of unnecessary medication. Over the years I have referred a variety of patients who I did not think had asthma for respiratory opinions. Confirmation that they did not have asthma did not make it any easier to find other treatment options. However, patients still seem to request asthma inhalers both from us and from out-of-hours services!
Prescribing restrictions
Our local commissioners have produced a long list of medication deemed to be of ‘low value’ and have recommended that we should ask patients to buy these themselves if they can afford to. Many of the drugs on the list are items that I would not either prescribe or recommend that they purchase. It might be worth looking to see whether your area is producing similar lists and discussing with colleagues what to recommend. It is usually better to give consistent advice to patients.
Eating disorders
A December BMJ issue had a series of articles on eating disorders. The ‘What your patient is thinking’ article gives some thoughts from a patient and her mother, about their views of the illness and treatment. The patient had a number of symptoms of anorexia, including amenorrhoea and significant weight loss, but describes not believing that the term ‘anorexia’ applied to her because her body mass index remained above 19.
Caitlin, S. (2017). I thought I wasn't thin enough to be anorexic. BMJ, 359(8133), 416–417.
Shoulder impingement
In a multi-centre trial of patients with shoulder pain, although the surgically treated groups had statistically better outcomes than the no-treatment group, these differences were small and not clinically important. This parallels similar research on the effectiveness of knee arthroscopy and makes me think that this uncertainty should be shared with patients when we make the decision to refer.
Beard, D., Rees, J., Cook, J., Rombach, I., Cooper, C., Merritt, N.,…, Carr, A. (2017). Arthroscopic subacromial decompression for subacromial pain (CSAW): A multicentre, pragmatic, parallel, placebo-controlled, three-group randomised surgical trial. The Lancet Open Access. doi: 10.1016/S0140-6736(17)32457-1.
Early psychosis
I was lucky enough to do a psychiatry post as part of my GP training. In retrospect, I think this was probably the most useful of all my posts. We do not frequently see new presentations of psychosis in general practice, so without the psychiatry role it would have taken me some time to see enough patients to be comfortable managing them. There is increasing evidence that early intervention is important for better long-term outcomes. Paired articles in the BMJ give a summary of early psychosis and an outline of how to recognise psychotic patients and assess risk. Discussion with your trainer and other learning about psychosis should improve knowledge of local resources and may make experiences with your first few psychotic patients easier.
Sami, M., Shiers, D., Latif, S., & Bhattacharyya, S. (2017). Early psychosis for the non-specialist. BMJ, 359(8129), 242–244.
Sami, M., Shiers, D., Latif, S., & Bhattacaryya, S. (2017). How to approach psychotic symptoms. BMJ, 359(8129), 245–247.
Migraine and stroke
A large Swedish study has shown no overall association between migraine and stroke. A within-pair analysis of the subgroup of twins who had migraine with aura showed no significant association with stroke.
Lantz, M., Sieurin, J., Sjolander, A., Waldenlind, E., Sjostrand, C., & Wirdefeldt, K. (2017). Migraine and risk of stroke: A national population-based twin study. Brain, 140(10), 2653–2662.
Menopause
The BMJ has produced an up-to-date summary of non-hormonal treatments for menopausal symptoms. There is a useful flow chart suggesting possible management plans for vasomotor and for vaginal symptoms.
Hickey, M., Szabo, R., & Hunter, M. (2017). Non-hormonal treatment for menopausal symptoms. BMJ, 359(8131), 326–329.
Sciatica
There is lack of evidence that any painkillers are effective in the treatment of sciatica. One of the BMJ Uncertainties series gives a useful short description of a personalised approach to the options, and a reminder that about a third of patient improve in 2 weeks, and three-quarters have improved within 12 weeks.
Pinto, R., Verwoerd, A., & Koes, B. (2017). Which pain medications are effective for sciatica (radicular leg pain)? BMJ, 359(8125), 74–77.