User blog: Rcgp Learning
Dr. 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.
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.
- 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
- 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
- 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
As 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.
According 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:
(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]
The 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.
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.
Over 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.
Primary 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:
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% 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.
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
What 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.
With 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.
There 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.
Prostatitis 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:
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.
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.
Symptoms include problems with ejaculation, erectile dysfunction or decreased libido.
Examination 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.
(1) BJU International. Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline.  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
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.
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:
What could I do differently?
What are my key take-away messages?
What difference will this make to my practice?
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:
Improved interface for your test results
Improved responsiveness and clearer in-page navigation of the tool
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
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.
(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
Epilepsy 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).
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:
(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
Cow’s Milk Protein Allergy (CMPA) is one of the most common food allergies in children and infants and unfortunately it can also be clinically complex to diagnose. Most of the presenting symptoms can overlap with many other conditions that are common in infants, such as eczema, reflux and colic. Some infants also experience respiratory problems, such as cough, chest tightness, wheezing or shortness of breath (1).There are two different types of CMPA; immunoglobulin E (IgE)-mediated CMPA and non-immunoglobulin E (non-IgE)-mediated CMPA. IgE-mediated allergies often provoke an immediate reaction to milk consumption, typically involving skin reactions. Conversely, non-IgE-mediated allergies produce a delayed reaction, which may take hours or days to present. These symptoms are commonly gastrointestinal.
Whilst it’s important to identify the different types of CMPA, it can be a challenge to diagnose them. According to a survey of 201 UK GPs in 2013, 92% would like to be clearer on the options for diagnosis, and 91% would like to increase their understanding of how to manage CMPA in their patients (2).
The NICE clinical knowledge summary on ‘Cow’s milk protein allergy in children’ recommends a skin prick test or IgE antibody blood test as the first step to diagnosing IgE-mediated CMPA. Non-IgE-mediated CMPA can be trickier to diagnose and NICE suggests a trial elimination of cow’s milk for around 2-6 weeks, before reintroducing it again (1). It is clear that whenever CMPA is suspected, a good allergy-focused clinical history is needed, including personal and family history of atopy and the effects of any dietary manipulation.
As the majority of CMPA cases first present in primary care, the Milk Allergy in Primary Care (MAP) Guideline was introduced to provide support to GPs. It guides users through the process of recognition, diagnosis and management of CMPA, in the form of interactive and downloadable guides (3). To access the interactive or PDF version of the MAP Guideline, click here.
Once a diagnosis has been established, the next challenge for GPs is deciding on how the allergy can be managed. If a diagnosis is confirmed in a breastfed baby, it’s recommended that the infant’s mother eliminates dairy from her own diet to prevent the transfer of cow’s milk proteins. It’s also suggested that a calcium supplement (1000mg/day) and a vitamin D supplement (10mcg/day) are prescribed to the mother during the elimination period (4). If they need some support in going ‘dairy-free’, it can be advised that most food labelling gives a clear indication of dairy content and that ‘free-from’ aisles are now common in most supermarkets. Following the elimination diet, the mother may need to be referred to a dietitian, who can advise on when she can start reintroducing dairy.
For bottle-fed babies, the two types of alternative formulas available are extensively hydrolysed formulas (eHFs) and amino acid formulas (AAFs). eHFs are most commonly the first choice for infants with mild to moderate CMPA, as they are less likely to cause an allergic reaction. AAFs are recommended for infants with more severe reactions to cow’s milk, and are tolerated by most babies with CMPA (5). You can find a list of the specialised formulas available in the NICE clinical knowledge summary on ‘Cow’s milk protein allergy in children’
If an infant is diagnosed with non-IgE-mediated CMPA, they should generally follow a cow’s milk protein-free diet until around 9-12 months of age. After this, cow’s milk and any cow’s milk containing foods can be gradually introduced to test whether the infant has developed a tolerance. To help with this process, a group of dietitians from the UK Wessex Allergy Network devised a Milk Ladder. This provides the best available information in terms of allergenicity of foods and the type of milk they contain. You can access the Milk Ladder here.
You can find further information about CMPA on the Allergy UK website. From here, you can also read about Allergy Awareness Week, which runs from 25th April – 1st May 2017. The RCGP offers a free eLearning course on Allergy, which gives you 1.5 CPD hours.
RCGP Members can also find out more about CMPA from the following:
Differentiating milk allergy (IgE and non-IgE mediated) from lactose intolerance: understanding the underlying mechanisms and presentations
Diagnosis & Assessment of Food Allergy in Children & Young People
(1) NICE. Clinical knowledge summary on ‘Cows milk protein allergy in children. [Internet] Available from: https://cks.nice.org.uk/cows-milk-protein-allergy-in-children#!topicsummary
(2) Act on CMPA campaign survey of 201 GPs. 2013. Data on file
(3) Allergy UK. ‘iMAP Guideline’. [Internet] Available from: https://www.allergyuk.org/health-professionals/mapguideline
(4) Ludman, S., Shah, &., Fox, A.T. ‘Managing Cow’s Milk Allergy in Children’ BMJ 2013;347:f5424. [Internet] Available from: http://www.bmj.com/content/347/bmj.f5424
Baker, G., Meyer, R. and Reeves, L. (2014) Food fact sheet: suitable milks for children with cow's milk allergy.The British Diabetic Association. [Internet] Available from: https://www.bda.uk.com/foodfacts/CowsMilkAllergyChildren.pdf
Prostate cancer is the most common cancer in men, with around 47,000 men diagnosed each year in the UK (1), causing 11,287 deaths in 2014 (2). March is Prostate Cancer Awareness Month, organised by Prostate Cancer UK, and with various prostate cancer events taking place throughout the month, you may find that more patients want to ask about PSA testing and whether they can have the test.
As GP referral is the route with the highest proportion of cases diagnosed at an early stage for prostate cancer, PSA testing in primary care is an important part of the diagnostic chain. The pros and cons of PSA testing in asymptomatic men has been passionately discussed over the years though there is evidence that in some patients it can pick up prostate cancer before symptoms appear and can even identify fast-growing cancers at an early stage.
The Prostate Cancer Risk Management Programme (PCRMP) was reviewed in 2016 to better inform GPs on the best approach. Based on the PCRMP guidelines (1) and suggestions from Prostate Cancer UK (2)(3), here are some key points to take away:
• Any man in the UK aged 50 and over who asks for a PSA test and carefully considers the implications with their GP is should be tested
• Those considered ‘high risk’ for prostate cancer are aged 50 or over, men with a family history of the disease and black men
• The PCRMP guidelines apply when discussing the test with asymptomatic men aged 50 and over who proactively ask about it, not high risk men or men of any age who have symptoms
• GPs should consider offering a digital rectal examination (DRE) to all asymptomatic men who have decided to have a PSA test
• The new recommended prostate biopsy referral value for men aged 50-69 has changed to ≥3.0ng/ml
• The PSA test can miss about 15% of cancers
• All men have the option to be re-tested in the future if their PSA test result is ‘normal’
If you would like to read more about PSA testing and the guidelines around it, here are some resources that may be useful for yourself and your patients:
PCRMP Pack – Further reading on the revised PCRMP guidelines from PHE
PSA Resource Pack – Expert information for healthcare professionals from Prostate Cancer UK
Best Practice Case Studies – A selection of case studies you could apply to your practice from Prostate Cancer UK
The Tool kit – A resource to help men who have been diagnosed with prostate cancer from Prostate Cancer UK
NHS decision aid – An online tool to help men decide whether to have the PSA test from the NHS
In addition to the resources above, you can also find a selection of eLearning materials from the RCGP. Our Prostate Cancer: Early diagnosis in General Practice course is FREE to all healthcare professionals and counts towards your CPD hours. If you’re an RCGP member, you can also access the following courses:
(1) Public Health England. Prostate specific antigen testing: summary guidance for GPs [Internet]. Available from: https://www.gov.uk/government/publications/prostate-specific-antigen-testing-explanation-and-implementation
(2) Cancer Research UK. Prostate cancer mortality statistics. [Internet]. Available from: http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/prostate-cancer/mortality
(3) Prostate Cancer UK. Prostate Cancer UK policy position on the PSA test [Internet]. Available from: http://prostatecanceruk.org/media/2493257/prostate-cancer-uk-policy-position-on-the-psa-test-2016.pdf