User blog: Rcgp Learning
It is Anger Awareness Week during the first week of December, an event which aims to bring the issue of problematic anger out in the open and encourage people to manage their anger effectively. Whilst anger can be a significant problem for adults, it is also common in children. For many children and young people, anger is simply a basic emotion to navigate as they grow up, but for some it can develop into something more serious.
Anger is a powerful emotion and is considered a necessary tool for survival as it is closely linked to the ‘fight or flight’ response. It prepares the body for the ‘fight’ option by keeping the body and mind stimulated through the arousal of the sympathetic nervous system. The physical effects of this include an increase in heart rate, blood pressure, blood flow to voluntary muscles, blood glucose level, respiratory rate and sharpness of senses, which are all necessary when the body needs to be on high alert1. The feeling of anger is often brought on by a combination of factors; a trigger event, an individual’s personality and their perception of the situation2.
In children the behavioural expressions of anger can seem dramatic, with outbursts such as screaming, shouting and throwing objects. In young children this is a normal part of emotional development, as they start to become more independent and therefore frustrated by situations which challenge their autonomy3. As children get older it may become more apparent if anger is turning into a problem, where it starts getting out of control and harming the child and/or the people/things around them. According to the mental health charity Mind4, examples of unhelpful angry behaviour include:
- Outward aggression and violence – shouting, swearing, slamming doors, throwing objects and being physically violent or verbally abusive towards others.
- Inward aggression – self-loathing, denying basic needs (such as food or happiness), cutting off from the world and self-harming.
- Passive aggression – ignoring people, refusing to do tasks, deliberately doing things badly, late or at the last minute and being sarcastic and sulky.
If the anger starts having implications in a child’s daily life, such as school exclusions and physical fights, their parents may well approach their GP to seek advice. At this point it’s important to consider whether the anger is actually a symptom of an underlying health problem.
Anger plays a big part in conduct disorders which are relatively common mental health conditions in children and young people that cause defiant, aggressive or antisocial behaviour. Younger children may have ‘oppositional defiant disorder’ which is a type of conduct disorder that involves arguing and disobeying but exhibits less antisocial behaviour5. According to the NHS, conduct disorders are the most common reason that children are referred to mental health services and 5% of all children aged 5-16 years old are diagnosed with the condition, with higher rates of diagnosis in boys than in girls5. The NICE guideline on ‘Antisocial behaviour and conduct disorders in children and young people: recognition and management’ recognises the discussion around the possible social determination of these disorders and the risk of overmedicalisation. Nevertheless it argues that “advances in the last three decades have shown that in addition to social causes there are substantial genetic and biological contributions to conduct disorders/antisocial behaviour; therefore, the contribution of these factors needs to be assessed and factored into intervention plans”.
NICE recommends that any children or young people who are suspected of having a conduct disorder should be assessed by health or social care professionals. Referral to child and adolescent mental health services (CAMHS) may also be necessary if the condition requires a multidisciplinary team or if there is diagnostic uncertainty. The initial assessment involves checking for any coexisting mental health problems or a neurodevelopmental condition, such as attention deficit hyperactivity disorder (ADHD) or autism6. More information about conducting these assessments can be found here. If a conduct disorder is diagnosed or any other conditions are detected, it’s important to treat these issues first and assess whether there have been any improvements to the anger problems.
Whether there is an underlying cause or not, parents will need to be supported in dealing with their child’s anger. The NHS provides advice on how to tackle anger together with the child, helping them to recognise the triggers and then use strategies to manage it. This information can be found here. Young Minds also has a section about ‘Responding to anger’ which is aimed at parents who are struggling to deal with their child’s anger and aggression. Parent training programmes and resources may also help with developing skills to manage difficult behaviour. Links to more information about these programmes can be found below. 9, 10, 11, 12
1 Mental Health Foundation. 2008. Boiling Point: And What We Can Do About It. https://www.mentalhealth.org.uk/publications/boiling-point-anger-and-what-we-can-do-about-it
2 Mental Health Foundation. 2018. Anger and Mental Health. https://www.mentalhealth.org.uk/a-to-z/a/anger-and-mental-health
3 Royal College of Psychiatrists. 2017. Dealing with tantrums: for parents and carers. https://www.rcpsych.ac.uk/mental-health/parents-and-young-people/information-for-parents-and-carers/dealing-with-tantrums-for-parents-and-carers
4 Mind. 2018. How to cope with anger. https://www.mind.org.uk/information-support/types-of-mental-health-problems/anger/
5 NHS. 2013. New guidelines on child antisocial behaviour. https://www.nhs.uk/news/pregnancy-and-child/new-guidelines-on-child-antisocial-behaviour/
6 NICE. 2017. Antisocial behaviour and conduct disorders in children and young people: recognition and management. https://www.nice.org.uk/guidance/cg158
7 Priory Education and Children’s Services. 2018. ADHD and when misbehaving becomes more than “playing up”. https://www.priorychildrensservices.co.uk/news-blogs/adhd-and-when-misbehaving-becomes-more-than-playing-up/
8 National Autistic Society. 2018. Information for general practitioners. https://www.autism.org.uk/professionals/health-workers/gp-info.aspx
9 YouTube. 2014. Parentchannel.tv https://www.youtube.com/user/parentchannelvideos/videos
10Family Lives. 2018. Parents Together Online course. https://www.familylives.org.uk/how-we-can-help/online-parenting-courses/parents-together/
11 YouTube. 2017. Parent-Plus TV. Anger & Aggression in children. https://www.youtube.com/watch?v=6-IafKUklUk
12 Care for the Family. 2018. Time Out for Parents: Handling Anger in the Family. https://www.careforthefamily.org.uk/courses/parenting-courses-time-out/time-out-for-parents-handling-anger-in-the-family
Flu season starts in late September/early October and lasts until the following March/April. During this time, GP consultations for flu-like symptoms usually increase from a baseline of 30 per 100,000 population. If the consultation rate rises above 200 per 100,000 population, a flu epidemic is declared¹.
Anyone infected with the flu virus is contagious up to a day before the onset of symptoms and for 5-7 days after the symptoms start. Even if patients are asymptomatic, they can still pass the virus on to others¹. The flu vaccine is the most effective protection against flu offered in the UK, and although it doesn’t guarantee that patients won’t catch flu, it is likely that any flu-related illness they contract after the vaccination will be milder and short-lived². During the 2017/18 flu season it’s estimated that around 14 million adults and children in England were vaccinated against flu³, and changes to the 2018/19 flu vaccination programme mean that it will be offered to around 24 million people this year⁴. The recommended composition of the vaccines is determined by the World Health Organisation, who reviews the types of flu that have circulated in all parts of the world and chooses the strains to be included in the vaccine for the following autumn. A summary of the recommended vaccines for 2018/19 can be found here. In 9 out of 10 years, the vaccine matches the flu strains circulating that year but sometimes there can be unexpected changes to the virus that affect the efficacy of the vaccine³.
One of the biggest changes to the 2018/19 flu vaccination programme is the addition of a new vaccine, which will be offered to over 65s. The adjuvanted trivalent vaccine (aTIV) contains adjuvant MF59, a substance that strengthens the body’s immune response³, as older adults’ immune systems can get progressively weaker over time, leaving them more susceptible to catching flu and suffering complications due to a reduced production of B and T cells and reduced functioning of mature lymphocytes¹. The vaccine is inactivated and protects against the three strains which are most likely to circulate this season. Public Health England (PHE) predicts that the introduction of this vaccine could reduce GP consultations in England by 30,000, admissions by over 2,000 and prevent over 700 deaths from flu⁴.
The Office of National Statistics (ONS) estimated that there were around 34,300 excess winter deaths in the 2016/17 period, with one third due to respiratory illnesses⁵, concluding that this was likely to be due to the predominant strain that year having a significant impact on elderly patients. Catching flu can place a considerable strain on the body in elderly patients: current estimations are that around two thirds will be temporarily housebound and a quarter will become temporarily bedbound. Amongst those that survive hospitalisation, around 13% will face disability and potential loss of independence and quality of life¹. There is also a risk of fatal co-morbidities, such as stroke, congestive heart failure and pneumonia¹.
All healthcare professionals can access the RCGP’s new Influenza in the elderly eLearning course for free, which is worth 0.5 CPD points. A detailed description of the different 2018/19 flu vaccines can be found in PHE’s guide for healthcare professionals.
¹ Royal College of General Practitioners. Influenza in the elderly eLearning course. [Internet]. Available from: http://elearning.rcgp.org.uk/course/view.php?id=294
² NHS. Vaccinations. The flu vaccine. [Internet]. Available from: https://www.nhs.uk/conditions/vaccinations/flu-influenza-vaccine/
³ Oxford Vaccination Group. Inactivated Flu Vaccine. [Internet]. Available from: http://vk.ovg.ox.ac.uk/inactivated-flu-vaccine
⁴ Public Health England. Press release: New flu vaccine available this winter for those aged 65 and over. [Internet]. Available from: https://www.gov.uk/government/news/new-flu-vaccine-available-this-winter-for-those-aged-65-and-over
⁵ Office of National Statistics. Excess winter mortality in England and Wales: 2016 to 2017 (provisional) and 2015 to 2016 (final). [Internet]. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/excesswintermortalityinenglandandwales/2016to2017provisionaland2015to2016final
World Psoriasis Day takes place every year on 29th October. It aims to raise awareness of the condition and provide support to people with psoriasis, which affects around 2% of people in the UK. It can start at any age in both men and women, but it typically develops in adults under 35¹.
Psoriasis is a complex, chronic, multifactorial inflammatory skin condition with an increase in the epidermal cell turnover rate. Like other autoimmune diseases, psoriasis can wax and wane, with patients varying between mild and severe symptoms depending on systemic, environmental and personal factors. Normally, skin cells are produced and replaced every 3-4 weeks, but in areas affected by psoriasis this process only takes around 3-5 days. This results in a build-up of epidermal hyperplasia which creates patches of scaly and erythematous skin².
Its pathogenesis is still not completely understood. It is likely that there is a genetic susceptibility to psoriasis, although it is not a genetic condition in itself. Immune dysfunction can also contribute. Excessively rapid production of keratinocytes leads to infiltration of T cells, dendritic cells, macrophages and neutrophils, causing inflammation³.Flares in psoriasis can be caused by a variety of factors, including non-immunological problems. A list of the most common of these can be found here on the NHS website.
Aside from the physical symptoms of psoriasis, it is also a visible condition which can affect many areas of a patient’s life. The psychosocial impact of psoriasis is not always considered during treatment, but it can affect a person’s functioning in life, work, relationships and social situations. According to a membership survey conducted by the European Federation of Psoriasis Patient Associations (EUROPSO), 77% of respondents said that psoriasis was a problem or a significant problem for their lifestyle and well-being⁴. Another study, that focussed on patient experiences of living with psoriasis, reported that the emotional and social impacts were frequently mentioned during interviews with the participants. Feelings of anger, frustration, shame and self-consciousness were reported. The social impacts discussed included avoidance of social activities and meeting new people⁵.
Psoriasis can also affect the quality of life for families of patients with psoriasis. A 2006 study found that the lives of relatives and partners can be significantly affected by the condition. Only 8% of participants reported that their quality of life wasn’t affected at all. 57% stated that they were psychologically affected, with feelings of anxiety, upset and worry about their relative/partner’s future. 55% reported social disruption due to lack of confidence or embarrassment and 44% said that leisure activities were limited by their relative/partner’s psoriasis. The study concluded that clinicians should consider appropriate care strategies for not only the patients, but also their families⁶.
Although the psychosocial impact of psoriasis is often difficult to avoid, GPs can play an important role in helping patients to overcome any difficulties they may face as a result of their condition. A 2016 review about ‘The Potential Psychological Impact of Skin Conditions’⁷ outlines a few suggestions of how to do this during a consultation:
- Managing the patient’s expectations
Before treatment starts, discuss with the patient about what outcomes are most important to them, what they expect to see and how possible it is to achieve this. By discussing their expectations in a realistic and practical way, the patient is more likely to comply to the treatment and recognise if the treatment isn’t working for them.
- Encouraging patients to see beyond the symptoms
Patients can feel impaired by the symptoms of their psoriasis and the degree of impairment can vary between people. Support from the GP is needed for patients to see beyond this and recognise that their symptoms don’t need to rule their life. A way of addressing this is to ask the patient “what would/could you do if you did not have these symptoms?”. Referral to mental health professionals may also help to provide patients with coping mechanisms.
- Helping patients to explain their symptoms
A large part of a patient’s psychosocial issues may be that they feel self-conscious about their visible psoriasis symptoms. Having to explain their condition and face potentially negative reactions from other people can be a source of anxiety. GPs can equip patients with the right words to explain their psoriasis, giving them an appropriate and informed range of responses to use if necessary. This will empower them to take control in social situations and feel comfortable discussing their condition. The ‘living with psoriasis’ patient leaflets by Leo Pharma suggest some simple ways that patients can explain their condition.
You can find out more about psoriasis in our eLearning resources. RCGP members can benefit from free access to EKU12: Assessment & Management of Psoriasis and EKU Podcast: Assessment & Management of Psoriasis. All healthcare professionals can also access the ‘Inflammatory conditions’ in the Dermatology Library for free.
The ‘See Psoriasis: Look Deeper’ campaign has some useful documentation for patients, which you can access here. The following video ‘The skin I’m in’ also provides in-depth accounts from psoriasis patients. It was produced by See Psoriasis: Look Deeper, Dermatrust and The Royal Free Hospital.
¹ NHS. Psoriasis Overview. [Internet]. Available from: https://www.nhs.uk/conditions/psoriasis/
² NHS. Psoriasis Causes. [Internet]. Available from: https://www.nhs.uk/conditions/psoriasis/causes/
³ Cai, Y., Fleming, C., Yan, J. (2012) New insights of T cells in the pathogenesis of psoriasis. Cel Mol Immunol 9(4) 302-309. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4132586/
⁴ Dubertret L, Mrowietz U, Ranki A, et al. EUROPSO Patient Survey Group. European patient perspectives on the impact of psoriasis: the EUROPSO patient membership survey. Br J Dermatol 2006;155(4):729–36
⁵ David Pariser, Brad Schenkel, Chureen Carter, Kamyar Farahi, T. Michelle Brown, Charles N. Ellis & for the Psoriasis Patient Interview Study Group (2016) A multicenter, non-interventional study to evaluate patient-reported experiences of living with psoriasis, Journal of Dermatological Treatment, 27:1, 19-26, DOI: 10.3109/09546634.2015.1044492
⁶ Eghlileb, A. , Davies, E. and Finlay, A. (2007), Psoriasis has a major secondary impact on the lives of family members and partners. British Journal of Dermatology, 156: 1245-1250. doi:10.1111/j.1365-2133.2007.07881.x
⁷ Tuckman, A. (2016) The Potential Psychological Impact of Skin Conditions. Dermatol Ther (Heidelb) (2017) 7 (Suppl 1):S53–S57. DOI 10.1007/s13555-016-0169-7
Alopecia is a general term for hair loss. However, there are different types depending on the severity and underlying cause of the hair loss. Alopecia areata is a non-scarring hair loss, which results in a small, round patch of baldness on the scalp. It can also affect hair across the body, such as facial hair, body hair, eyebrows and eyelashes. For some people, larger areas can be affected, such as the whole scalp (alopecia totalis) or the whole scalp and body (alopecia universalis)².
Alopecia Awareness Month takes place in September and aims to raise awareness of alopecia and the impact it has on those it affects. It is estimated that the lifetime prevalence of alopecia areata in the UK is 1.7%, with both men and women affected¹. Patients with concerns about hair loss symptoms are likely to visit their GP initially, so it is useful to have some understanding of alopecia and the different ways it can present.
Alopecia areata is an autoimmune condition which occurs when T-lymphocytes attack the hair bulb. There is a genetic predisposition in some families and it can also be associated with other autoimmune conditions, such as thyroiditis, lupus erythematosus, vitiligo and psoriasis¹. Unfortunately, there is no known cure and hair regrowth cannot be guaranteed. The chances of the hair growing back depends on the amount that is lost in the first place. People with small bald patches may experience full regrowth within a year, whereas people who lose half of their hair may not make a full recovery².
Another cause of alopecia is androgenetic alopecia, which can affect men or women and for which there is a genetic link. Treatments for this include antiandrogens and hair transplants, which are not usually available on the NHS.
Telogen effluvium is another common form of alopecia. It occurs when hair follicles move from the anagen phase to the telogen phase too early. Around 85% of scalp hairs are in the anagen phase, which means that the hair grows by 0.5-1.5cm a month and lasts in the scalp around three-five years. Telogen is when the hair follicle is approaching the end of its lifecycle. The hair is fully keratinized and the follicle is dormant, lasting in the scalp around two-three months¹.
The normal hair cycle is illustrated in the diagram below:
Acute telogen effluvium can happen suddenly and generally comes on about three months after a trigger. Common triggers include childbirth, severe trauma or illness, a stressful or major life event, rapid weight loss, severe skin problems affecting the scalp or a new medication¹’³. Patients may notice large numbers of hairs on their pillow, hairbrush or in the plughole. In most cases, hair growth returns to normal within a few months¹. If the hair loss carries on for more than six months, this could suggest chronic telogen effluvium. It is more common in women and is linked to female pattern hair loss, thyroid disease and iron and vitamin D deficiencies¹.
The RCGP has recently developed an eLearning course with Alopecia UK, with the aim of increasing GPs’ knowledge of hair loss conditions. You can access the Alopecia eLearning course here. The course is FREE to access and gives you at least 0.5 CPD Credits upon completion. For more information on hair loss conditions, you can also visit the Alopecia UK website here.
¹ Royal College of General Practitioners. Alopecia eLearning course. [Internet]. Available from: http://elearning.rcgp.org.uk/course/view.php?id=283
² British Association of Dermatologists. Alopecia Areata Patient Information Leaflet. [Internet]. Available from: http://www.bad.org.uk/for-the-public/patient-information-leaflets/alopecia-areata
³ British Association of Dermatologists. Telogen Effluvium (a type of hair loss) Patient Information Leaflet. [Internet]. Available from: http://www.bad.org.uk/for-the-public/patient-information-leaflets/telogen-effluvium
The first week of August marks World Breastfeeding Week, which aims to encourage mothers around the world to breastfeed and therefore safeguard the health of their babies. August was chosen because the Innocenti Declaration was signed in August 1990 (and later updated in 2005) by governments and various health organisations to protect, promote and support breastfeeding¹. The awareness week is coordinated by World Alliance for Breastfeeding Action (WABA), a global network consisting of several organisations such as World Health Organisation (WHO), United Nations Children’s Fund (UNICEF) and La Leche League International (LLLI)². World Breastfeeding Week has taken place every year since 1992, and has a different theme and focus each time. As well as a theme, each year there are four objectives: Inform, Anchor, Engage and Galvanise.
The theme for this year’s World Breastfeeding Week is ‘Foundation of Life’, which references the health benefits that breastfeeding provides for both mother and baby: breastfeeding exclusively for 6 months can help protect against infections and therefore reduce newborn mortality. It also provides an important source of nutrients and energy in early life and reduces the likelihood of obesity in childhood and adolescence. For the mother, a longer duration of breastfeeding can reduce the risk of developing breast or ovarian cancer ³. According to a 2014 study on 10,000 new mothers in the UK, breastfeeding was also linked to lower rates in post-natal depression. Mothers who planned to breastfeed and actually went on to breastfeed were 50% less likely to suffer with post-natal depression than those who hadn’t planned to and didn’t breastfeed.⁴
To get the optimum benefits from breastfeeding, WHO and UNICEF recommend the following³:
- early initiation of breastfeeding within one hour of birth
- exclusive breastfeeding for the first six months of life
- combination of nutritionally adequate solid foods with continued breastfeeding up to two years of age and possibly beyond
Despite the benefits the rates for breastfeeding in the UK are among the lowest in the world⁵. According to the latest Infant Feeding Survey in 2010, only 34% of babies in the UK were receiving any breastmilk at six months⁶, compared to 49% in the US and 71% in Norway⁵. Breastfeeding initiation was at 81% and went down to 1% for exclusive breastfeeding by the six month mark⁶.
The Infant Feeding Survey also states that eight out of ten women stop breastfeeding before they want to. Common reasons for stopping breastfeeding included problems with the baby’s latch, painful breasts or nipples and feeling that they had an ‘insufficient’ milk supply⁶. Although most of these issues may be addressed initially with midwives, health visitors and lactation consultants, it’s important for GPs to have enough knowledge about them to advise mothers at their 6-8 week check. For more information about how to deal with these common problems appropriately, you can consult the NICE Clinical Guideline on ‘Postnatal care up to 8 weeks after birth’. NHS Choices also provides more information about specific conditions such as mastitis and tongue-tie. GPs can signpost patients to organisations such as The Breastfeeding Network and LLLI for further support and advice.
Although breastfeeding is the recommended infant feeding method by many health organisations, GPs may also be asked for advice on formula feeding as an alternative. While the role of the primary care team is crucial in promoting exclusive breastfeeding both pre and post natal, it is crucial to offer support to women who chose the alternative. The RCGP offers a FREE eLearning course on Infant Nutrition, which covers the basics of formula feeding and provides an understanding of common feeding problems.
For further information about breastfeeding and the GP’s role, the RCGP has recently launched an eLearning course on Breastfeeding, which is FREE to all healthcare professionals.
¹ World Health Organisation (WHO). World Breastfeeding Week 1-7 August 2016. [Internet} Available from: http://www.who.int/mediacentre/events/2016/world-breastfeeding-week/en/
² World Health Organisation (WHO). BREASTFEEDING: Foundation of Life. 2018. [Internet]. Available from: http://worldbreastfeedingweek.org/
³ World Health Organisation (WHO). Infant and young child feeding. February 2018. [Internet]. Available from: http://www.who.int/en/news-room/fact-sheets/detail/infant-and-young-child-feeding
⁴ Borra, C., Iacovou, M. & Sevilla, A. Matern Child Health J (2015) 19: 897. Available from: https://doi.org/10.1007/s10995-014-1591-z
⁵ Victora CG, Bahl R, Barros AJD, et al, for The Lancet Breastfeeding Series Group. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet 2016; 387: 475–90
⁶ McAndrew F, Thompson J, Fellows L, Large A, Speed M, Renfrew MJ (2012) Infant Feeding Survey 2010, Health and Social Care Information Centre. Available from: https://files.digital.nhs.uk/publicationimport/pub08xxx/pub08694/infant-feeding-survey-2010-consolidated-report.pdf
At RCGP, we want to do our best to deliver the best support and value possible, especially when it comes to your learning. That’s why we’re pleased to announce that from this month, GP SelfTest will now be a FREE learning resource for all RCGP members.
RCGP has invested in GP SelfTest as an online tool for all our members, whatever stage of your career you are. You may be a trainee starting out on your journey into general practice and need support with familiarising yourself with the RCGP curriculum and revising for the Applied Knowledge Test (AKT) or further along in your profession as an independent GP, preparing CPD for your appraisal and revalidation. GP SelfTest can help you to identify your learning needs and build upon these to improve your practice.
With GP SelfTest, all RCGP members can now have FREE unlimited access to different tests, thousands of questions written by GPs and comprehensive feedback with up-to-date resources to aid your further study.
With close to 6,000 users, here’s a little of what some GPs have to say about using GP SelfTest:
So why not join them today and see how GP SelfTest can support your learning? Don’t miss out and claim your free access here.
Please note, if you are an RCGP member who has recently purchased a subscription and would like to discuss a partial refund, please contact our GP SelfTest team on: GPSelfTest@rcgp.org.uk
At the RCGP you are part of a community. A community that provides its members with networks for support and advice, a collective voice for GPs and opportunities for innovation and research. It’s a community that values your learning and wants to ensure you’re always learning, throughout your career as a GP.
Developed by GPs for GPs, the college offers many high-quality educational resources. As well as supporting your learning, these resources are a great way to boost your CPD credits. As an RCGP member, you can also benefit from accessing the majority of our resources for free.
There are currently two topics in this brand new resource, with many more being added over the next year. As an introduction to the Educational Libraries, this blog post outlines some of the ways you can utilise this resource to meet your learning needs.
How can these libraries help me?
The Educational Libraries provide you with a great opportunity to explore other aspects of general practice.
Supporting your CPD, these libraries bring together national guidelines and educational resources such as eLearning, journal articles and podcasts that are relevant to GPs and other primary healthcare professionals. Information on relevant courses you can attend are also included to help you learn from peers, gain networking opportunities and to really get the most out of being a GP.
What is included in this series?
Content from the Women’s health library has been viewed over 29,000 times since its launch in May 2017.
Content from the Dermatology library has been viewed over 6,000 times since its launch in March 2018.
How can I access the Educational Libraries?
Visit the RCGP’s online learning environment and select the ‘Educational Libraries’ section on the homepage.
You’ll find that the resources have been organised in a clear and user-friendly format designed to help GPs meet their learning needs and improve opportunities to specialise and diversify in their career.
1 May marks World Asthma Day, an annual event organised by the Global Initiative for Asthma (GINA). The event aims to raise awareness and improve asthma care around the world¹. It’s estimated that around 5.4 million people in the UK are currently receiving treatment for asthma, which amounts to around one in 12 adults².
According to Asthma UK, around three people die each day from asthma attacks and the UK has one of the highest death rates from asthma in Europe².
The National Review of Asthma Deaths (NRAD) was the first UK-wide investigation into asthma deaths, which looked into the 195 deaths that occurred between 2012 and 2013³. The review considered various areas of asthma care, such as use of NHS services and prescribing and medicines use. Another area that was investigated was ‘medical and professional care’ which found that out of the 195 people that died, only 44 (23%) had been provided with personal asthma action plans (PAAPs). For 84 people (43%), there was also no evidence that an asthma review had taken place in general practice within the last year before their death³.
The review also found that 61% of the deaths were of people that suffered from only mild or moderate asthma³. The NRAD concluded that their asthma was likely to have been poorly controlled and undertreated, which highlights the need for good control. While asthma is managed in both primary and secondary care, it is likely that patients will return to primary care to regularly monitor and review their asthma.
The 2016 guideline produced by the British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN) states that asthma is best monitored in primary care by an annual clinical review. For adults, they recommend that the following factors should be monitored and recorded⁴:
- Symptomatic asthma control
- Lung function assessed by spirometry or by peak expiratory flow (PEF)
- Asthma attacks, oral corticosteroid use and time off work since last assessment
- Inhaler technique
- Bronchodilator reliance
- Possession of and use of a self-management plan/personal action plan.
To monitor symptomatic asthma control, both the BTS/SIGN and NICE guidelines recommend using a validated questionnaire that uses directive questions, such as the Asthma Control Test or the Royal College of Physicians’ ‘3 questions’⁴’⁵. To help with identifying and managing any red flags that arise as a result of the clinical review, the NICE Clinical Knowledge Summary for asthma can be accessed here.
NICE have recently issued some updated guidelines for the management of asthma and you can access a summary of the updates here.
The RCGP offers various eLearning materials on asthma and the following resources are FREE to all healthcare professionals:
Asthma – 1 CPD credit
Common atopic presentations in primary care – 5 minute screencast on asthma
Single Inhaler Therapy for Asthma – 5 minute screencast
RCGP members can also benefit from access to the following resources:
EKU18 – Wheeze & Asthma in Young Children
EKU 2017.2 – Management of asthma
EKU 2018.2 – Diagnosis, monitoring and chronic asthma management
EKU podcasts – Asthma: introduction to Asthma, Asthma: NRAD report and Asthma Management Guidelines, Asthma: Management of the Asthma Patient
- Tiotropium in asthma: what is the evidence and how does it fit in?
- Over diagnosis of Asthma in Children in Primary Care
- Increased versus stable doses of inhaled corticosteroids for exacerbations of chronic asthma in adults and children
- Does inhaler choice matter?
- Systematic meta-review of supported self-management for asthma: a healthcare perspective
- Vitamin D supplementation to prevent asthma exacerbations
(1) The Global Initiative for Asthma (GINA). World Asthma day. Available from: http://ginasthma.org/wad/
(2) Asthma UK. Asthma facts and statistics. Available from: https://www.asthma.org.uk/about/media/facts-and-statistics/
(3) Royal College of Physicians. Why asthma still kills. The National Review of Asthma Deaths (NRAD). [May 2014]. Available from: https://www.rcplondon.ac.uk/file/868/download?token=JQzyNWUs
(4) British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN). British guideline on the management of asthma. . Available from: https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/
(5) NICE. Asthma: diagnosis, monitoring and chronic asthma management (NG80). [November 2017]. Available from: https://www.nice.org.uk/guidance/ng80
It is estimated that around 17% of the UK’s population have Irritable Bowel Syndrome (IBS)1, but there is no single cure that works for all patients. April marks IBS Awareness Month, aiming to spread important information about diagnosis and management of this often uncomfortable and painful condition.
A recent development in IBS treatment is the introduction of the low FODMAP diet – standing for Fermentable Oligo-saccharides, Di-saccharides, Mono-saccharides and Polyols.
The low FODMAP diet was developed in Australia by a team at Monash University in Melbourne2 after finding that foods high in certain short-chain carbohydrates can cause gastrointestinal discomfort. Short chain carbohydrates are poorly absorbed in the small intestine and are found in various foods, such as wheat, rye, pulses, lactose, fructose and some fruit and vegetables. These high FODMAP foods increase the amount of water in the small intestine which can contribute to loose stools. They start fermenting when they reach the colon, which may increase gas production and subsequently cause symptoms such as wind and bloating3. You can find examples of high and low FODMAP foods on the Monash University website here.
A 2017 review that assessed the results of published clinical studies on FODMAP, concluded that up to 86% of patients with IBS saw an improvement in overall gastrointestinal symptoms4.
As the symptoms of IBS can be similar to those of other diseases such as Inflammatory Bowel Disease (IBD) or bowel cancer, the NICE Pathway for IBS recommends looking for red flag indicators when a patient presents with IBS symptoms, to assess whether the patient should be referred to secondary care for further investigations5. More information about these red flags can be found here in the NICE Pathway.
While the efficacy of the low FODMAP diet seems impressive, patients should be referred to a dietitian before attempting it on their own, as recommended in the NICE guidance on IBS6. When a patient is referred to a dietitian, there will be three stages:
- Low FODMAP Diet - the patient will reduce their intake of high FODMAP foods for two-six weeks to establish whether the symptoms will respond to the change in diet.
- Re-challenge phase – if symptoms have improved, high FODMAP foods will be introduced for six-eight weeks so the patient can identify which FODMAPs trigger their symptoms.
- Adapted diet – the dietitian will personalise the diet to the patient, so they only avoid their ‘trigger foods’ and can resume a more normal diet2.
For further information about gastrointestinal conditions, the RCGP offers the following eLearning courses that are FREE to all healthcare professionals:
Inflammatory Bowel Disease - 0.5 CPD credits
Managing uncertainty in lower gastrointestinal tract presentations - 0.5 CPD credits
Diagnosis and Management of Coeliac Disease - 0.5 CPD credits
RCGP members can also benefit from access to the following content:
(1) Khanbhai. A and Singh Sura. D. Irritable Bowel Syndrome for Primary Care Physicians. [March 2013] Available from: http://www.bjmp.org/content/irritable-bowel-syndrome-primary-care-physicians
(2) Monash University. The Low FODMAP Diet. [Internet] Available from: https://www.monashfodmap.com/
(3) Magge. S and Lembo. A. Low-FODMAP Diet for Treatment of Irritable Bowel Syndrome. [Nov 2012] Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3966170/
(4) Nanayakkara. W.S. (et al). Efficacy of the low FODMAP diet for treating irritable bowel syndrome: the evidence to date. [June 2016] Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4918736/
(5) NICE pathways. Irritable bowel syndrome in adults overview. Interactive flowchart. Available from: https://pathways.nice.org.uk/pathways/irritable-bowel-syndrome-in-adults
(6) NICE. Irritable bowel syndrome in adults: diagnosis and management (CG61). [April 2017] Available from: https://www.nice.org.uk/guidance/cg61/chapter/1-Recommendations#dietary-and-lifestyle-advice
The Dermatology library is the latest addition to the RCGP’s Educational Libraries. It has been developed in partnership with the Primary Care Dermatology Society (PCDS) and the British Association of Dermatologists (BAD) and is free to access here.
The Dermatology library brings together national guidance, dermatology resources and RCGP accredited courses relevant to GPs and other primary healthcare professionals. It presents a variety of resources to suit your preferred method of learning, including screencasts and podcasts. The major areas in dermatology are presented in a clear and user-friendly format providing you with quick access to topics of interest, including:
• Dermatology overview
• Infection and infestation
• Genetic and systemic disorders
• Inflammatory conditions
• Specific lesions
• Urticaria and blistering.
These resources will support you as a GP to meet your clinical and CPD needs and improve your opportunities to specialise and diversify in your career, supporting the GPs with Extended Roles (GPwER) programme and accreditation process.
The Dermatology library will form part of a series of clinical, non-clinical and professional educational libraries the RCGP will publish with specialist organisations. In this series, you can also access the Women’s Health Library here.