Abstract
Transition to adult care
Over the years I have seen a variety of problems when children with long-term conditions transition to adult care. Lucy Watts gives a patient’s view of this and makes suggestions on how the process could be improved.
Watts L (2018) Stepping up to adult services. BMJ 362(8169): 412–413. DOI: 10.1136/bmj.k3886.
Undescended testes
A BMJ Practice Pointer article has summarised assessment and management of undescended testes. The article includes written and diagrammatic information about how to palpate undescended testes and a reminder to urgently refer children with bilateral impalpable testes, penile abnormalities or ambiguous genitalia.
In primary care the authors suggest review at 3 months and referral, without imaging, of those who still have undescended testes.
Cho A, Thomas J, Perera R, et al. (2019) Undescended testis. BMJ 364(8193): 536–538. DOI: 10.1136/bmj.l926.
IMG Conference
‘Relatable, grateful and feeling energised’ was how a GP trainee described his experience after attending an International Medical Graduate (IMG) conference. This conference, like the latest General Medical Council report ‘Fair to refer’, highlighted how little is done to support the vital IMG workforce. Dr Farah Jameel, a renowned GP leader, and other leading IMG speakers spoke about their own challenges within the NHS before they became successful. Areas covered included interview skills, leadership, the impact of social media and handling complaints. The conference enabled IMG doctors to feel less isolated, become more aware of support systems and realise that they are not alone in their struggles.
Avascular necrosis
A young woman with avascular necrosis of the hip has contributed to an ‘Easily Missed’ article. She presented at aged 36 with severe left groin pain radiating to the knee, causing her to limp. Initial X-rays were normal so, despite ongoing pain, it was over a year before a magnetic resonance imaging (MRI) scan showed avascular necrosis with collapse of the femoral head.
This is a very rare condition. I have not seen one in over 30 years in primary care.
I think the common features of all the rare things I have diagnosed as a GP have been the need to listen to the story, to rethink if there is no answer within two to three consultations, and to share by discussion or referral if you don't know what is going on. As more of us take on portfolio careers, and time in the day to ‘chat about patients’ reduces, I think we need to make specific plans about how we share clinical dilemmas.
Lamb J, Holton C, O’Connor P, et al. (2019) Avascular necrosis of the hip. BMJ 365(8201): 325–327. DOI: 10.1136/bmj.l2178.
Compression-only CPR
Many bystanders are daunted, even if they have had training, about embarking on cardio-pulmonary resuscitation (CPR). A large Swedish study on out-of-hospital cardiac arrests has shown a significant increase in CPR by bystanders after guidelines endorsed compression-only resuscitation. If your patient participation group or other community organisations teach CPR, do you know what sort of guidelines they use?
Riva G, Ringh R, Jonsson M, et al. (2019) Survival in out-of-hospital cardiac arrest after standard cardiopulmonary resuscitation or chest compressions only before arrival of emergency medical services: Nationwide study during three guideline periods. Circulation 139: 2600–2609.
Self-harm in young people
A recently published study in the Lancet demonstrated rising rates of non-suicidal self-harm in teenagers, particularly in adolescent girls. The study highlights that there is an important role for primary care in providing information and support to patients around self-harm ‘without normalising it’. The charity Young Minds provides information and support around self-harm for young people, and also has information and a helpline for parents.
‘Cure’ and language we used in consultations
An interesting short piece in the BMJ highlighted the importance of the language we use with patients. The author, Amy Robertson, highlights how words like ‘cure’ are often loaded with negative connotations, and particularly for patients with chronic conditions, reframing ‘wellness’ in terms of life goals rather than physical measures may be more helpful for patients. I think it is worth a read.
Robertson A (2019) Let’s talk about the notion of cure. BMJ 365: l2051. DOI: 10.1136/bmj.l2051.
Yoga for menopausal symptoms
The menopause for some women is a challenging period of their lives, often not simply owing to the physiological changes. A systematic review and meta-analysis demonstrated that yoga may be useful in treating bothersome vasomotor and psychological symptoms. Often, we are trapped into the medical model of thinking of hormone replacement therapy (HRT) as a first-line management, but thinking broadly about the patient and more conservative lifestyle approaches this review offers an approach we could use to help patients manage symptoms.
Shepherd-Banigan M, Goldstein K, Coeytaux R, et al. (2017) Improving vasomotor symptoms; psychological symptoms; and health-related quality of life in peri- or post-menopausal women through yoga: An umbrella systematic review and meta-analysis. Complementary Therapies in Medicine 34: 156–164. DOI: 10.1016/j.ctim.2017.08.011.
Treatment of subclinical hypothyroidism
A recent change in my practice has been around management of subclinical hypothyroidism (SCH) after a large-scale review demonstrated that most patients with SCH do not gain benefit from treatment with levothyroxine, in terms of clinical symptoms. The exceptions are pregnant women, or patients with a thyroid stimulating hormone (TSH) over 20. Rather than treat, it is recommended that thyroid function tests are monitored to see whether the TSH is rising.
Bekkering G, Agoritsas T, Lytvyn L, et al. (2019) Thyroid hormones treatment for subclinical hypothyroidism: A clinical practice guideline. BMJ 14365: l2006. DOI: 10.1136/bmj.l2006.
Vestibular migraine
A condition I am aware of, but have felt perhaps under-confident in detecting clinically, is vestibular migraine. A helpful review in the BMJ highlights the International Classification of Diseases (ICD) diagnostic criteria, red flags to be aware of and management of the condition.
Li V, Mardle H and Anand Trip S (2019) Vestibular migraine. BMJ 366: l4213. DOI: 10.1136/bmj.l4213.
Social Prescribing Network
I have recently come across the ‘Social Prescribing Network’, which describes itself as a collective of ‘health professionals, researchers, academics, social prescribing practitioners, representatives from the community and voluntary sector, commissioners and funders, patients and citizens’ who have been setting up networks in England, Ireland and Scotland. The aim of social prescribing is to provide patients with a ‘link worker’ who they can have a face-to-face consultation with, to design their own social prescription in order to ‘improve their health and wellbeing’. Social prescribing incorporates a range of different approaches, such as increasing exercise and activity and work in the voluntary sector. The website contains a section with a wealth of resources, plus links to regional groups supporting social prescribing.
Role of genetics in obesity
There appears to be an increasing body of literature emerging about the role of diet in various conditions. A recent longitudinal study in Norway over 5 years found that body mass index (BMI) had risen both in those genetically predisposed and those not predisposed to obesity, indicating that ‘the environment remains the main contributor’. The authors state that this is evidence for preventative measures targeted at a population level. I think also it is important to be able to convey this message to patients: That though indeed some individuals may be genetically more likely to struggle with weight, overall this is an issue linked with western lifestyle.
Brandkvist M, Bjørngaard J, Ødegård R, et al. (2019) Quantifying the impact of genes on body mass index during the obesity epidemic: Longitudinal findings from the HUNT Study. BMJ 366: l4067.
Acute cough
National Institute for Health and Care Excellence (NICE) has produced guidelines on the management of acute cough, aiming to reduce unnecessary antibiotic prescribing. The guidance gives a reminder that acute cough is usually self-limiting, resolving without antibiotic treatment in 3 to 4 weeks.
The guidance does not recommend antibiotics for those who are not systemically unwell. There is a flow chart, written in clear English, for use with patients and showing them how you have reached the decision. It also lists the evidence for some over the counter remedies.
You can find the guidance and chart at www.nice.org.uk/guidance/ng120.