User blog: Rcgp Learning

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March is just around the corner, which means that time is running out to complete your appraisal and boost those Continuing Professional Development (CPD) points. If you’re looking for a way to save some time and ease the stress of preparing for your appraisal, the RCGP’s GP SelfTest tool may be the answer.

Breakdown%20of%20results.JPGWith around 5000 users over the past year, GP SelfTest is already a popular tool on the RCGP’s eLearning website. You may have seen that it’s a useful tool for AKT preparation, but qualified GPs can also benefit from using GP SelfTest for their CPD and to meet the requirements for their appraisal and revalidation.

GP SelfTest provides an easy way to identify your educational needs and focus on the key areas that form part of your professional development plan (PDP). The Curriculum Wide Learning Needs Assessment test is particularly useful for this, as the results provide a breakdown of any topics that need some improvement. You’re then signposted to any ‘Curriculum Resources’ on the RCGP eLearning website that can help with this.

Reflection%20notes.JPGWhile you’re busy working on your PDP, you can also clock up some CPD credits to add to your log. You can capture and track your improved learning with the results and certificate that GP SelfTest provides. The certificates automatically update with your results and the dates you completed your tests, so you don’t have to remember this information yourself. By adding these certificates to your portfolio and recording any improvements in your results, you can easily demonstrate to your appraiser that you’re fit to practise. You can read more about CPD credits and appraisal here.

There is also a reflection notes section on GP SelfTest, where you can capture your thoughts on what you have learned and ask yourself questions such as:

Tick%20icon%20cropped.pngHow will this learning/improved knowledge from GP SelfTest impact upon your practice?
Tick%20icon%20cropped.pngWhat have you done differently with your improved learning?
Tick%20icon%20cropped.pngWhat impact will your improved learning have on your patients?
Tick%20icon%20cropped.pngHas it helped you with a Quality Improvement Activity (QIA)?

Your notes can be printed with a certificate of your test results, and used as evidence of your CPD.

GP%20SelfTest-Icon-Print.jpgTo start making your appraisal preparation quicker and easier, you can purchase your subscription to GP SelfTest here. If you need some more information first, you can find out more about the tool and how it can benefit you by visiting the GP SelfTest homepage here.

[ Modified: Thursday, 1 February 2018, 10:28 AM ]

iStock-174753147.jpgIt’s estimated that over 1 million sexually transmitted infections (STIs) are acquired every day worldwide (1). Last year in England alone there were around 420,000 diagnoses of STIs, with chlamydia accounting for 49% of these (2). Despite the prevalence of STIs, many patients still choose not to go for regular sexual health checks. According to Public Health England’s 2017 report on STIs and chlamydia screening, there has been a decline in the number of STI tests carried out over the last 5 years (3).

National STI Day was launched a few years ago to encourage people to take responsibility for their sexual health and attend regular testing. It has been chosen to take place on the 14th January of each year, so that it falls two weeks after New Year’s Eve: a day when traditionally more alcohol than usual is consumed and people are more likely to engage in sexually risky behaviour. Various papers have demonstrated the link between alcohol, risky sexual behaviour and STI diagnoses, with women being more affected than men. (4) (5). This two week period after New Year’s Eve was deliberately chosen as the most common STIs can take two weeks to be detectable (6).

Despite that fact that STIs can lead to serious health problems, it seems that not everyone is as informed as they should be about the importance of safe sex. In 2016, the Family Planning Association (FPA) conducted a survey of more than 2,000 people aged 16 and over across the UK to find out what they knew and thought about safer sex and STI testing (7). Out of the findings of the survey, the following statistics are perhaps the most concerning:

  • 68% said that they had never had an STI test
  • 52% didn’t know that you can get an STI from oral sex
  • 71% said they did not use any form of condom the last time they had sex
  • Only 9% learnt at school about how to find and use sexual health services

iStock-649191108-%20cropped.jpgWhile genitourinary medicine (GUM) clinics are commissioned to screen for and treat STIs, patients frequently present in general practice to seek advice about STIs and contraception. It's important that GPs are able to have open and honest conversations about sex and sexuality, and know where to signpost patients to sexual health services outside of general practice.

There are a range of sexual health services available in the UK, but as the RCGP highlighted in the 2016 ‘Time to Act’ report, there is evidence of restricted access to contraception and STI testing depending on patients’ location or age (8). The report also expressed concerns about the way sexual and reproductive health services are commissioned and the training available for GPs in sexual and reproductive health (SRH) available to GPs. You can read the full report here

The RCGP offers various eLearning materials on sexual health and contraception and the following resources are FREE to all healthcare professionals:

Sexual Health in Primary Care – 2 CPD credits

Contraception – 1 CPD credit

HPV - the essentials – 0.5 CPD credits

Women’s Health Framework – Sexual and Reproductive Health Resources – some content is only free to RCGP members

RCGP Members can also benefit from access to the following resources:

EKU4 – Managing of genital chlamydia trachomatis infection

EKU9 – HIV in primary care and ‘HIV in primary care’ podcast

EKU2017.2 – Routine investigation and monitoring of adult HIV-1 positive individuals and increasing uptake of HIV testing

EKU hot topic (December 2014): HIV infection – Treatment and research

 

References:

(1)  World Health Organisation. 2016. ‘Sexually transmitted infections (STIs) factsheet’ [Online]. Available from: http://www.who.int/mediacentre/factsheets/fs110/en/    

(2)  Public Health England. 2017. ‘Infographic: Sexually transmitted infections and chlamydia screening in England, 2016’ [Online]. Available from: https://www.gov.uk/government/statistics/sexually-transmitted-infections-stis-annual-data-tables

(3)  Public Health England. 2017. ‘Sexually transmitted infections and chlamydia screening in England, 2016’ [Online]. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/617025/Health_Protection_Report_STIs_NCSP_2017.pdf

(4)  Hutton et al. 2008. ‘The Relationship between Recent Alcohol Use and Sexual Behaviours’. [Online]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2588489/

(5)  Connor et al. 2015. “Alcohol Involvement in Sexual Behaviour and Adverse Sexual Health Outcomes from 26 to 38 Years of Age”.  Plos One. Available from:  http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0135660

(6)  National STI Day website. http://www.stiq.co.uk/about/

(7)  Family Planning Association. 2016. ‘Sexual Health Week 2016’ [Online]. Available from: https://www.fpa.org.uk/sexual-health-week/sexual-health-week-2016

Royal College of General Practitioners. 2016. ‘Sexual and Reproductive Health Time to Act’ [Online]. Available from: http://www.rcgp.org.uk/-/media/Files/Policy/Media/8895-RCGP-Sexual-Health-online.ashx?la=en

[ Modified: Monday, 15 January 2018, 9:32 AM ]

iStock-599146694.jpgDr. Sam T. Claus was in the middle of a pleasant dream involving a mug of hot chocolate, several mince pies and a re-run of “It’s a Wonderful Life”. Inexplicably, the film was interrupted by a beeping noise and he woke to realise that his pager had gone off. Cursing the day when he decided to work in a practice that still does its own on call, he dialled the messaging service.

An hour later he was trudging through the snow to see Rudolph, a regular patient with a distinctive rhinophyma. Rudolph claimed this was due to rosacea, but Sam had his suspicions. Rudolph had told the messaging service that he was light-headed and thought it was his heart. Sam had other suspicions.

Sam found Rudolph on the sofa worse for wear snuggling with the remnants of a bacon sandwich. Concerned that getting close to Rudolph’s breath might get him into trouble with the local constabulary, Sam made a brief assessment and told Rudolph the unsurprising news that he had a hangover.

“But that’s not possible Doc”, exclaimed an indignant Rudolph “I’ve done my research”.

He pulled out a bag full of packets including some long-acting propranolol, a sachet of dried yeast and some fructose tablets.

“I’ve been online doc, any one of these will sort out a hangover and I took all three. There must be something wrong with me”.

“Aha” said Sam “you’ve consulted Dr. Google? I’m afraid he has led you astray. A meta-analysis of online hangover cures1 has clearly shown that none of them are any use – the only prevention is to drink moderately, or not at all. Have some paracetamol and lots of water– you’ll feel better soon”.

Sam left Rudolph to sleep it off, heading for the local nursing home where he was due for a ward round. He paused to pick up his beagle, Comet, this being an enlightened home which felt that the residents would benefit from contact with animals. As he made his rounds, Sam couldn’t resist the chocolates on most of the nursing stations and he reflected on how likely it would be that the boxes would still be there that evening. Probably not, a study having shown that the mean survival time of a chocolate on a hospital ward is 51 minutes2, with half the box generally being eaten in under two hours.

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Sam’s mood worsened when he was asked to see Mrs. Blitzen, an elderly woman with severe diarrhoea following a course of co-amoxiclav. Cursing the overuse of broad-spectrum antibiotics, Sam approached her room and was amazed to see Comet race ahead of him, bark and lay down against her door. A sudden flash of recognition hit Sam as he remembered that Comet had taken part in a study whereby beagles were trained to detect Clostridium difficile and could do so with over 90% sensitivity and specificity3. Pulling on his gloves he prepared to dazzle the nurses with his quick-fire diagnostic skills.

Later that evening, a colleague now on-call, Sam was delighted to find that “It’s a wonderful life” was actually on the TV. Settling down with a hot chocolate and a plate of mince pies he reflected on his day and the curiosities that he might come across the next time he had the joy of holding the on-call pager.

 

References:

  1. Pittler Max H, Verster Joris C, Ernst Edzard. Interventions for preventing or treating alcohol hangover: systematic review of randomised controlled trials BMJ 2005; 331 :1515
  2. Gajendragadkar Parag R, Moualed Daniel J, Nicolson Phillip L R, Adjei Felicia D, Cakebread Holly E, Duehmke Rudolf M et al. The survival time of chocolates on hospital wards: covert observational study BMJ 2013; 347 :f7198
  3. Bomers Marije K, van Agtmael Michiel A, LuikHotsche, van Veen Merk C, Vandenbroucke-Grauls Christina M J E, Smulders Yvo M et al. Using a dog’s superior olfactory sensitivity to identify Clostridium difficile in stools and patients: proof of principle study BMJ 2012; 345 :e7396
[ Modified: Friday, 1 December 2017, 11:48 AM ]

iStock-178897619.jpgAs the campaign to overcome the stigma attached to mental health continues, self-harm is one of many symptoms of mental health issues that may present in primary care, particularly in children and young people. According to the Royal College of Psychiatrists, around 1 in 10 young people at any age will self-harm at some point (1). Incidence may be even higher than this, as many patients don’t seek help.

When they do seek help, GPs are likely to handle the initial conversation with the young person, taking a history, finding out their methods and how often they self-harm, whilst trying to establish possible triggers and underlying causes. This may seem like an impossible feat during a 10-minute appointment, but up to date numbers on self-harm show the importance of effectively dealing with self-harm at the first presentation.

iStock-140472402_cropped.jpgAccording to a recent study published in the BMJ, there was a 68% increase between 2011-2014 in the number of girls aged 13-16 who reported self-harm to their GP (2) with a three times higher incidence rate than in boys. As shown before, those who self-harmed were at greater risk of suicide than those who didn’t. Out of the 16,912 records of self-harm that were examined in the study, the main methods were drug overdoses (84.1%) and self-cutting episodes (12.3%) (2). With these statistics in the media, they may raise awareness and subsequently encourage patients and/or their parents to visit their GPs. Self-harm has recently featured in popular TV programmes aimed at a younger audience: the teen soap opera Hollyoaks recently focussed on a group of female friends who turn to self-harm to cope with their personal struggles and looked at the impact this had on their lives. The subject was also touched upon in the controversial 2017 Netflix series 13 Reasons Why, which was criticised earlier this year for potentially glamorising suicide. Whilst the series primarily follows a suicidal teenager, it also makes reference to self-harm.

With a new spotlight on self-harm, it’s important for GPs to be aware of how to best manage these patients safely in primary care. The NICE clinical guideline on ‘Self-harm in over 8s: short term management and prevention of recurrence’ provides recommendations for all healthcare professionals and gives an overview of the next steps after a patient is referred.

For more information about how mental health issues in children and young people can be managed in general practice, we created the ‘Child and adolescent mental health’ course. The course is FREE to access for all healthcare professionals and will give you 1 hour towards your CPD. If you’re an RCGP member, you can also access the following resource:

EKU13: Depression in Children & Young People

 

References:

(1)  Royal College of Psychiatrists, 2016. ‘Self harm’ [Online] Available from: http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/self-harm.aspx [Accessed 25 October 2017]

BMJ. 2017. ‘Incidence, clinical management, and mortality risk following self-harm among children and adolescents: cohort study in primary care’ [online] Available at: http://www.bmj.com/content/359/bmj.j4351 [Accessed 25 October 2017]

[ Modified: Tuesday, 7 November 2017, 2:47 PM ]
Picture of Rcgp Learning
by Rcgp Learning - Wednesday, 11 October 2017, 11:15 AM

GPST_Cropped.jpgThe Applied Knowledge Test (AKT) exam is coming up this month, which may mean that you have booked your place and are now ready to get started on some revision. Preparing for an exam can be nerve wracking and many people have their preferred ‘revision routine’ to ensure that the information sticks in their mind.

To make revising easier, the RCGP provides a tool called GP SelfTest, which is specifically geared towards preparing you for your AKT exam. The content is aligned with the RCGP curriculum, so you can be confident that you’re starting in the right place with your exam prep. GP SelfTest’s value goes beyond AKT too as its structure around the RCGP curriculum can help you create ePortfolio entries on what you have learnt and those areas that are more difficult.

Whether you already have your ‘go to’ revision method or you’re open to some tips, here are just some of the ways that GP SelfTest can adapt to your learning styles:

I prefer to revise…on the go

If you have some time to kill on your commute or you simply prefer to get out of the house when revising, you can take GP SelfTest with you. It can be used on tablets and mobile devices so you have an excuse to take a break from your computer.

I prefer to revise…in small chunks

Using an online tool to revise gives you the flexibility to dip in and out of the content. If you start a test on GP SelfTest, you can stop at any time and pick up where you left off when you’re ready to go back to it.

I prefer to revise…with a time limit

Some people find that learning under pressure works better for them. With the AKT mock exams on GP SelfTest, you have the option to select a timed test that replicates the amount of time you will have on the day.   

I prefer to revise…by setting goals

After completing one of the AKT mock exams, GP SelfTest gives you the option of tracking and analysing your test results. This will give you an idea of what you need to work towards. The tool will also show you a benchmark comparison between your results and those of your peers.

I prefer to revise…by targeting improvement areas

If you’re not sure which areas require the most attention, you can take the Curriculum Wide Learning Needs Assessment exam, which contains a sample of questions from each topic. Based on your results, you can then complete a Topic-Specific test to further your knowledge.GP%20SelfTest-Icon-Print.jpg

To explore GP SelfTest for yourself and to see how it can fit in to your revision methods, you can access the tool here. Over 100 new questions have recently been added, with more coming soon.

For a first-hand account of how GP SelfTest helped Dr Rasitha Perera to prepare for his AKT exam, you can read his blog post here.

[ Modified: Wednesday, 11 October 2017, 11:19 AM ]

anxious personOver the last few months the population of the United Kingdom has witnessed an unusually high number of national tragedies in quick succession: the terror attacks in Manchester, Westminster, London Bridge, Finsbury Park and the devastating fire at Grenfell Tower.

There is clear evidence that traumatic events such as these can lead to the development of a range of psychological and mental health issues, such as adjustment and anxiety disorders, depression, and post-traumatic stress disorder (PTSD). While the spectrum of responses to these traumatic events is broad, they will nevertheless impact on the patient’s ability to function, on their relationships and their ability to work and socialise.

Some of those exposed will experience only a short-term period of distress of up to four weeks, but those who do not recover may develop more serious mental health problems. Even people who are not in close physical proximity to these events may experience heightened anxiety, and there will be some who will be particularly concerned due to real or perceived discrimination because of their religion and/or their ethnicity.

Current PTSD prevalencePrimary care is facing significant and ongoing demands due to these events, as initial treatment is likely to be sought in general practice settings. While the vast majority of GPs will be familiar with the signs and symptoms of the aforementioned mental health problems, the diagnosis of post-traumatic stress disorder may be missed or attributed to depression or anxiety disorders.

To find out what we in general practice could do, I spoke to Dr Jonathan Leach, a GP in Bromsgrove with a special interest in post-traumatic stress disorder and was able to ask him a few questions. Jonathan served 25 years in the military and has personal experience of responding to and supporting colleagues and patients who have been involved in major incidents. I also had a look at the literature on PTSD in primary care and especially the ‘normal response’ to traumatic events and how we can support victims (including ourselves) in general practice.

As expected, the choice of literature is vast, so I started with the 2005 NICE guideline on PTSD (Jonathan Leach is one of the members of the NICE committee working on the update), which as usual was good value. I also liked the Royal College of Psychiatrists guidance on ‘coping after a traumatic event’ which listed the range of emotions and responses to expect after being exposed after a traumatic event. Under the ‘What happens next’ heading, the team of authors listed a range of emotions that victims might be experiencing:

  • Frightened … that the same thing will happen again, or that you might lose control of your feelings and break down
  • Helpless … that something really bad happened and you could do nothing about it. You feel helpless, vulnerable and overwhelmed
  • Angry … about what has happened and with whoever was responsible
  • Guilty … that you have survived when others have suffered or died. You may feel that you could have done something to prevent it
  • Sad … particularly if people were injured or killed, especially someone you knew
  • Ashamed or embarrassed … that you have these strong feelings you can't control, especially if you need others to support you
  • Relieved … that the danger is over and that the danger has gone
  • Hopeful … that your life will return to normal. People can start to feel more positive about things quite soon after a trauma.”

In our conversation Jonathan emphasised that it is important for us to acknowledge to the patient that it’s normal and acceptable to feel like this. He also felt that we should allow our patients to express these feelings and give them time and empathy. Only if the patient does not improve after some time and the feelings and memories are becoming more intrusive, is it time to think about our diagnoses. The so-called ‘normal’ response can vary considerably: some patients will develop a marked reaction that resolves over a few weeks, while others have no or very little symptoms.

PTSD in primary care is common, but underdiagnosed: prevalence of PTSD is around 6-10%Initial treatment sought in GP settings in the civilian population, so we should see a considerable amount of patients with these symptoms, though maybe sometimes without recognising the underlying diagnosis. There seems to be moderate evidence that the primary care PTSD screening test (PC-PTSD) has good accuracy as a screening tool in both military and civilian settings in high risk populations and it is easy to administer in just a minute or two. Jonathan reminded me that those high-risk populations are not only veterans and patients who have suffered a recent mass traumatisation event such as the Grenfell Tower fire, but also women suffering sexual violence. The National Women’s study reported that almost one in three female victims of sexual violence develop PTSD at some stage during their lives. These are often events that can go back a long time, so it is important that the symptoms are recognised and specialised PTSD treatment can be initiated. Brief psychological trauma focused interventions (five sessions) may be effective if treatment starts within the first month after the traumatic event for symptomatic patients, but beyond the first month, treatment should be trauma-focused CBT or EMDR. This of course depends on the availability of PTSD-focussed care on your patch.

For those of us who have been involved in traumatic events at work or outside the workplace, it is important to realise that just because we are doctors we are not immune to developing these symptoms. There are some papers examining the PTSD rates among emergency medicine and other hospital doctors, suggesting the numbers to be around 12-13%, higher than in the general population. I couldn’t find any numbers on PTSD in general practitioners but wouldn’t be surprised if the numbers are similar. Having psychological symptoms resulting from the things we have been exposed to at work is therefore not unusual, and if concerned, seek help from your own GP (or the NHS GP Health Service) and get advice, treatment and if necessary, take some time off.

While not everybody might share my taste in TV-Drama, I always thought the award winning West Wing episode “Noël” dealt with PTSD in a rather mature and touching way, and – while for most health professionals a bit too overdramatised and simplistic – demonstrates the intrusiveness of flashbacks and the emotional changes that victims can go through when exposed to traumatic events. Maybe one to watch on the weekend.

References:

Bisson et al (2007): Early Psychosocial Intervention Following

Traumatic Events. Am J Psychiatry 164:1016 - 1019

Royal College of Psychiatrists (2013): Post-Traumatic Stress Disorder; http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/posttraumaticstressdisorder.aspx retrieved 04/08/2017

Royal College of Psychiatrists (2014): Coping after a traumatic event; http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/copingafteratraumaticevent.aspx retrieved 04/08/2017

National Institute for Health and Care Excellence (2005): NG26 Post-traumatic stress disorder;

Bisson JI et al: Early Psychosocial Intervention Following Traumatic Events. Am J Psychiatry July 2007, 164:1016-1019

Sonis, J: PTSD in Primary Care—An Update on Evidence-based Management. Current Psychiatry Reports, Jul 2013, 15:373

Sorkin, A: Noël. The West Wing. Warner Bros; Dec 2000

Spoont et al (2015): Does This Patient Have Posttraumatic Stress Disorder?: Rational Clinical Examination Systematic Review. JAMA Aug 04; 314(5), 501-10

Tjaden, P., & Thoennes, N. (1998). Prevalence, Incidence, and Consequences of Violence Against Women: Findings From the National Violence Against Women Survey. National Institute of Justice Research in Brief. Retrieved from https://www.ncjrs.gov/pdffiles/172837.pdf

Wilberforce et al (2010): Post-traumatic stress disorder in physicians from an underserviced area. Family Practice, 27(3), 333-343

[ Modified: Thursday, 14 September 2017, 4:11 PM ]

GP_cropped.jpgWhat are the questions going to be like? What are the areas I need to focus on? Do I need to focus on breadth of knowledge or detail or both? These are just a few of the questions I usually contemplate when preparing for an exam… and ones I felt I was able to answer prior to sitting my Applied Knowledge Test (AKT), thanks to RCGP’s latest learning resource – GP SelfTest.

Training to be a GP – an expert generalist – is challenging. The curriculum is broad and the need to cover this is reflected in the wide clinician experiences that we come across in our speciality training years. The need for Continuing Professional Development (CPD) and self-assessment therefore is ever more important.

Quote%201.jpgWith this in mind, the RCGP have developed GP SelfTest – a tool for AiTs and qualified GPs’ post Certificate of Completion of Training (CCT) to help identify and assess areas of learning. Having used the tool initially to help prepare for the AKT exam, I have come to appreciate its use not just as a revision aid but also to ensure that I can continually pinpoint and focus my learning long term.

The questions are usefully presented in a number of different ways. I started with the Curriculum-wide Learning Needs Assessment. This was particularly useful in taking that all important but scary first step into starting revision! This was a random selection of 100 questions that after answering, gives a breakdown of results by curriculum area and compares to results from peers. It usefully links to associated eLearning courses, EKUs and podcasts for each category in the RCGP curriculum.

Quote%202.jpgThere are also the options to filter a set of questions to a particular topic, have a “lucky dip” of a set number of questions or to sit a timed or untimed AKT Mock exam. Being able to focus on a topic/curriculum helps consolidate knowledge after a particular clinical rotation or learning experience such as paediatric rotation or dermatology clinic. Not only does it help ensure that knowledge learnt from a clinical setting is relevant to the GP curriculum but it can also help those wanting to develop areas of expertise.

There is a choice between a six months or 12 months subscription and you can get further information on GP SelfTest here: www.rcgp.org.uk/GPSelfTest. GP SelfTest is continuously being developed and the question bank being added to, so now is a great time to sign up and ensure you are prepared in being that expert generalist!

Rasitha Perera is a GPST2 doctor based in the Chesterfield training programme. He is the current Vice Chair of the RCGP AiT Committee and Committee Lead for the Learn work-stream.

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[ Modified: Tuesday, 1 August 2017, 11:27 AM ]

iStock-597256602.jpgProstatitis is a very common condition in men. According to a systematic review, 8.2% of men had prostatitis symptoms out of a selection of over 10,600 participants. (1). It is particularly prevalent in those aged 35-50 (2). Prostatitis covers a range of conditions such as acute bacterial prostatitis (ABP), chronic bacterial prostatitis (CBP) and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).

Although the symptoms of prostatitis present regularly in primary care, it can be a challenge for GPs to make a correct diagnosis due to the broad spectrum of causative triggers.

To establish a diagnosis of CBP or CP/CPPS, the patient should have a history of persistent or recurrent symptoms for a minimum of three out of the past six months, though often suspicion is raised after a shorter duration of symptoms. For CP/CPPS there is no ‘gold standard’ for definitive diagnosis, so it is typically based on the patient’s history and excluding other possible causes (1).

A definitive diagnosis of CBP relies on the presence of a recurrent urinary tract infection (UTI) and isolation of an aetiologically recognised organism from prostatic fluid or urine, though often treatment is commenced before an aetiologically recognised organism is cultured.

The four main categories of symptoms are as follows:

Urogenital pain

Pain could be from physical dysfunction, neuropathy and/or inflammation, with the most common sites being the prostate or pelvic floor muscles. A retrospective study showed that patients most commonly complained about pain in the perineal, testicular, pubic and penile areas.

Psychological issues

There is growing evidence that depression, anxiety and panic disorders are more common in men with chronic pelvic symptoms, compared to other men.

Lower Urinary Tract Symptoms (LUTS)

These include voiding symptoms such as weak stream, straining and hesitancy or storage symptoms such as urgency, incontinence, frequency, nocturia and dysuria.

Sexual dysfunction

Symptoms include problems with ejaculation, erectile dysfunction or decreased libido.

iStock-588242562.jpgExamination of patients with the symptoms of CP/CPPS should include the abdomen, external genitalia, bladder, perineum and a digital rectal examination. To rule out CBP and ABP, a urine dipstick and/or MSU for culture and microscopy should be arranged as well as sexually transmitted diseases screening. If appropriate, a prostate specific antigen test should be arranged, though levels can be elevated with prostate enlargement, infection, inflammation, so it might need to be postponed during the acute flare.

To assess severity and improvement of symptoms, the international prostate symptom score can be used.

Management is unsurprisingly varied and multi-modal and often based on expert or consensus opinion, as there is still lack of gold standard evidence. It ranges from antibiotics and alpha blockers to physiotherapy and CBT. The EKU module on ‘Chronic Prostatitis and Chronic Pelvic Pain Syndrome’ has a detailed work-up on treatment and management in primary care.

Patients should be reviewed 4-6 weeks after the initial presentation, with no further action required if the symptoms have resolved, but referral to specialist care should be considered at initial presentation if there is diagnostic uncertainty or symptoms are severe and require immediate specialist attention.

These patients require a holistic approach to their symptoms, and a good social, psychological and sexual history are important in their management.

For further and in-depth advice on diagnosis and management of chronic prostatitis and chronic pelvic pain syndrome, refer to EKU 15’s module on the topic.

 

References:

(1) BJU International. Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. [2015] Available from: http://onlinelibrary.wiley.com/doi/10.1111/bju.13101/pdf

(2) Prostate Cancer UK. Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. [September 2014] Available from: https://prostatecanceruk.org/media/2491363/pcuk-chronic-prostatitis-guideline-full-sept-2015.pdf

[ Modified: Thursday, 6 July 2017, 11:00 AM ]

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Your day to day frontline experience as a GP faces the recurrent themes of being task driven and time starved. The King’s Fund reports that the total number of face-to-face appointments with GPs has increased by 13.2 per cent over the past five years (1). There’s those urgent queries not booked in for appointments, the increased demand for face-to-face appointments, over-running clinics, managing expectations of the public, urgent phone calls to discuss medication, urgent prescriptions that need signing, the lab results to check and action, supervision, home visits, practice meetings… and then there needs to be time for revision and revalidation.

The RCGP wants to support you in achieving your revision and revalidation goals, so we recently launched GP SelfTest as the new RCGP accredited learning needs assessment tool for GPs at all career stages. This has been well received by Associates in Training (AiTs), RCGP members and peers in the wider GP profession. GP SelfTest aligns itself to the RCGP Curriculum, which outlines the skills and expertise you require to be able to practice as a GP in the United Kingdom. It allows you to choose from a selection of different tests that are tablet and mobile friendly so that you can test your knowledge in practice, at home or on the go, pausing tests and finishing sessions at times convenient for you.

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The next Applied Knowledge Test (AKT) assessment is coming up on 25 October 2017. For AiTs, you can use GP SelfTest to get a head start with your AKT revision and practice with tests such as the AKT Mock Exams in timed and untimed conditions. By focusing on the AKT Mock Exams, you can take these tests an unlimited amount of times in individual sessions of 200 questions which can be paused and re-visited at any time; there are no demands on you to answer all questions in one sitting. After you have submitted a test, GP SelfTest will track and analyse your test results, providing a full breakdown of your performance across the RCGP curriculum to identify and target the areas that require improvement and will show you a benchmark comparison against your peers’ average scores.

For qualified GPs, you can utilise GP SelfTest throughout the year for your Continuing Professional Development (CPD) to support you in meeting the requirements for appraisal and revalidation. Tests such as the Curriculum Wide Learning Needs Assessment (100 questions per session) and Topic-Specific tests (20 questions per topic in a session) will help you explore your knowledge and explore your current learning needs. You’ll benefit from easy access to comprehensive feedback to questions and links to even more digestible, user-friendly and up-to-date resources for further study. On GP SelfTest, you can use the reflection notes section to capture your thoughts on what you have learned and ask yourself questions such as:

Tick%20icon%20cropped.png What could I do differently?
Tick%20icon%20cropped.png What are my key take-away messages?
Tick%20icon%20cropped.png What difference will this make to my practice?
Tick%20icon%20cropped.png How will I know/measure if this learning has successfully had an impact?

These reflection notes can be printed as a certificate, with a certificate of your test results, and used as evidence of your CPD in your ePortfolio.

In our users’ words, GP SelfTest has been described as: “an official question bank” with “good structure and content of questions” and “easy to use, attractive layout” that is a “better price than most”.

We want to help make things work better and ensure GP SelfTest is responsive to your needs. We’ve been listening to our users, monitoring feedback and using this to inform future developments. Recently, based on user feedback, GP SelfTest was upgraded with added features to aid your learning, such as:

Tick%20icon%20cropped.png Improved interface for your test results
Tick%20icon%20cropped.png Improved responsiveness and clearer in-page navigation of the tool
Tick%20icon%20cropped.png Inclusion of reflection boxes and certificates.

We welcome all feedback and for those users who have completed the GP SelfTest feedback form, we thank you for taking the time to do so. It is thanks to you and the feedback you provide that GP SelfTest continues to develop to meet your day-to-day

GP%20SElfTest%20-%20female%20GP.jpgComing up
We will be adding a further 1,000 questions to the GP SelfTest question bank which are being rigorously quality assured to save you time and ensure you are provided with the most recent and relevant clinical knowledge and RCGP’s mark of excellence.

Free two week trial of GP SelfTest
RCGP members are eligible for a free two week trial of GP SelfTest. Further information can be found here.

References:

(1) The Kings Fund. Understanding pressures in general practice. [May 2016] Available from: https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/Understanding-GP-pressures-Kings-Fund-May-2016.pdf

[ Modified: Wednesday, 6 September 2017, 9:36 AM ]

iStock-594937808.jpgEpilepsy is a common neurological disorder, with an estimated 87 people diagnosed in the UK every day (1). The clinical aspects of epilepsy are predominantly dealt with in secondary care but GPs may still be asked for practical advice from those living with the condition. Something that women may approach their GP about, for example, is advice on the methods of contraception available to them, and the potential risks involved when using these alongside their anti-epileptic drugs (AEDs).

It is recommended in the SIGN clinical guideline 143 on ‘Diagnosis and management of epilepsy in adults’, that advice about contraceptive methods should ideally be given to women with epilepsy before they become sexually active (2). However, to be able to do this, it’s important that GPs have access to the latest guidance on AEDs, and the possible drug interactions that could occur when using hormonal contraception.

For women with epilepsy, the advice they are given on hormonal contraception depends on the type of AED they are taking. AEDs can be separated into enzyme-inducing and non-enzyme inducing drugs, which can have different interactions when combined with hormonal contraception. The most common enzyme-inducing AEDs are carbamazepine, phenytoin, phenobarbital, primidone and topiramate.

Those taking enzyme-inducing drugs can be at risk if they are using any form of combined hormonal contraception. If the patient takes the combined oral contraceptive pill (COCP), they have more likelihood of breakthrough bleeding and contraceptive failure due to accelerated oestrogen metabolism. Enzyme-inducing drugs also increase progesterone metabolism, therefore it is recommended to avoid prescribing the progesterone-only oral contraceptive (POP) and progesterone implants. Progestogen injections and the levonorgestrel intrauterine system can be used, but patients should be made aware that the progestogen injection is associated with a reduction in bone density (2). In terms of emergency contraception, patients can choose between a copper intrauterine device (Cu-IUD) or a double dose of the levonorgestrel ‘morning after pill’ (2 x 1.5 mg tablet). Ullipristal emergency contraception is not suitable for use in women taking any enzyme-inducing anti-epileptics (2).

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According to the Faculty of Sexual Reproductive Healthcare (FSRH), although lamotrigine is not thought to be an enzyme inducer, oral forms of contraception are not recommended due to potential interactions with the drug (3). Lamotrigine levels can be affected by combined hormonal contraceptives, causing a reduction in lamotrigine exposure, leading to reduced seizure control and the risk of toxicity in the hormone-free week. Conversely, the POP may increase lamotrigine levels.

Whilst sodium valproate is not an enzyme inducer, it carries a high risk of developmental disorders (four in 10) and birth defects (one in 10) when taken in pregnancy, so effective contraception is required (4). The progestogen-only implant, the progestogen-only injectable and intrauterine contraceptives are recommended options because they are less user-dependent than other methods and provide the best protection with 'typical' use (5).

The FSRH states that women with epilepsy can be reassured that the efficacy of both intrauterine contraception (Cu-IUD and LNG-IUS) and injectable contraception (DPMA) are not affected by any AED interactions (3). A full list of AEDs and recommended contraception methods can be found in the SIGN clinical guideline 143. For up to date information on potential interactions, you can refer to the online drug interaction checker on the Medscape website.

To find out more about patients living with epilepsy, please visit the Epilepsy Action website. From here, you can also read about Epilepsy Awareness Week, which runs from 14th – 20th May 2017. For further information on epilepsy or contraception, the RCGP also offers the following FREE eLearning courses:

Sudden Death in Epilepsy (SUDEP) and Seizure Safety - 0.5 CPD hours
Contraception – 1 CPD hour

RCGP members can also access the following resources on Epilepsy:

EKU17: Diagnosis & Management of Epilepsy in Adults

EKU12: Quality Standards for Epilepsies in Adults, Children & Young People

EKU Screencast: Quality Standards for Epilepsies in Adults, Children & Young People

References:

(1) Epilepsy Action. What is Epilepsy? [Internet] Available from: https://www.epilepsy.org.uk/info/what-is-epilepsy
(2) Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of epilepsy in adults. Edinburgh: SIGN; 2015. (SIGN publication no. 143). [May 2015]. Available from: http://www.sign.ac.uk
(3) Faculty of Sexual Reproductive Healthcare (FRSH). Clinical Guidance: Drug Interactions with Hormonal Contraception. [January 2017] Available from: https://www.fsrh.org/standards-and-guidance/documents/ceu-clinical-guidance-drug-interactions-with-hormonal/drug-interactions-final-15feb.pdf
(4) Medicines and Healthcare products Regulatory Agency. Toolkit on the risk of valproate medicines in female patients. [February 2016]. Available from: https://www.gov.uk/government/publications/toolkit-on-the-risks-of-valproate-medicines-in-female-patients
(5) Faculty of Sexual Reproductive Healthcare (FRSH). Statement from the Clinical Effectiveness Unit: Sodium Valproate and Pregnancy Risks. [February 2016]. Available from: https://www.fsrh.org/standards-and-guidance/documents/ceustatementsodiiumvalproate/ceustatementsodiiumvalproate.pdf

[ Modified: Friday, 12 May 2017, 3:56 PM ]
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