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Written by Dr Toni Hazell

Please note further updates may be made to this blog to reflect the concerns about hormonal contraception and meningioma.

Progestogens – in various delivery methods - are commonly used for contraception in the United Kingdom. Oral progestogen-only preparations contain either levonorgestrel, norethisterone, desogestrel, or drospirenone, while combined with an oestrogen desogestrel, gestodene, drospirenone, levonorgestrel, norethisterone and norgestimate are used. The commonest progestogen used in the depot injection is medroxyprogesterone acetate (MPA) – norethisterone enantate is also licensed in the UK but rarely used. The implant contains etonogestrel and levonorgestrel is the progestogen used in intra-uterine devices (IUDs). 

Progestogens have for some time been identified as an independent risk factor for meningioma, the most common intracranial tumour in adults, representing around 38% of all primary central nervous system (CNS) tumours and around 53% of all benign brain tumours¹. Meningiomas are usually benign, but can cause seizures, cognitive impairment, and focal neurological deficits and frequently require neurosurgical and/or radiation therapy. 

Recently, the Patient Safety Commissioner responded to concerns from the public and support groups regarding the association between prolonged use of medroxyprogesterone and an increased risk of intracranial meningioma. There have been several studies in this area from 2024 to 2026; this blog will outline the key features that GPs need to know to be able to counsel their patients on this matter. Those who wish to look in more detail at the studies will find information about them in the CoSRH documents published in March 2024², July 2025³, June 2026⁴ and July 2026⁵. 

The main risk factors for meningioma are age and female sex; incidence per 100,000 of the population rises from 0.16 under the age of 19 to 18.69 over the age of 40⁴. With uncommon conditions such as this, the need to understand the difference between absolute and relative risk is vital. For example, a woman using the depot injection is, on average, 9.7 times more likely to have a meningioma than one who isn’t using the depot, but for someone in their early 30s, the number needed to harm (NNH) is 24,238 i.e. this number of women would need to use the depot for their to be one extra case of depot associated meningioma⁵. Most of us would react quite differently to being told that there is a nearly 10-fold increase in risk, compared to being told that nearly 25,000 people would have to use this medication for one to be caused harm. Those who wish to know more about how to counsel on absolute and relative risk might want to look at the RCGP ‘Five minutes to change your practice’ screencast on explaining risk to patients.

In brief, the links between meningioma and progestogens are as follows, as we understand them in September 2026: 

• The highest odds ratio is for MPA (9.70) – all the other progestogens known to be associated with increased risk have an odds ratio between 1.62 and 2.53. This list consists of combined oral contraception (COC) containing cyproterone, desogestrel, drospirenone, gestodene or levonorgestrel, the desogestrel progestogen only pill (POP) and the 52mg levonorgestrel intrauterine device (LNG-IUD). 
• The absolute risk for all of these progestogens is small – the 2026 paper gives an overall NNH of 4,337 for the MPA depot, with the desogestrel POP, the 52mg LNG-IUD (Mirena®, Benilexa® and Levosert®) and COCs containing cyproterone, desogestrel and drospirenone having NNHs of between 20,000 and 30,000. The desogestrel POP and the gestodene containing COCs have NNHs above 30,000.
• As mentioned above, for younger women with a lower background risk, the NNH falls even further. For example, for those aged under 19, the NNH for the MPA injection is close to 500,000 and for the 52mg LNG-IUD it is over 2.5 million. 
• There is no increased risk of meningioma with the norethisterone POP, COCs containing norethisterone and norgestimate and the lower dose LNG-IUDs (Kyleena® and Jaydess®). There is also clearly no increased risk with the non-hormonal methods such as the copper IUD or condoms. 

CoSRH advice in their various documents on this matter is as follows:

• When we are counselling patients who are starting or continuing hormonal contraception, we should explain that meningioma is an uncommon tumour which is usually benign and that the absolute risk remains low – this is particularly the case for younger women⁵. 
• Women starting methods containing cyproterone acetate, nomegestrol acetate, MPA or desogestrel should particularly be informed about the increased risk of meningioma⁴. 
• The risk of meningioma should be considered alongside the benefits of effective contraception, using a shared decision-making process⁵.
• For women who are under the care of neurosurgery for a current meningioma, their specialist should be contacted for advice about continuing any form of hormonal contraception. Advice should also be sought before starting any hormonal contraception in women with a history of meningioma⁴.

This is a complex area – the mere mention of the words ‘brain tumour’ has the risk of causing panic among patients, and we do not want a relatively small risk to put our patients off from accessing reliable methods of contraception. Many of our patients will also be getting other benefits from their contraception (for example control of dysmenorrhoea, abnormal uterine bleeding or endometriosis) and we know that there are also long-term benefits, such as the halving of ovarian cancer risk in women who use the COC for 10 years, a benefit that persists for decades after stopping the COC⁶. Translating complex scenarios into words that our patients understand and helping our patients to understand the risks and benefits of any proposed intervention, so that they can make a decision that they are happy with, is what GPs do best. 

References:

1. Alruwaili AA, Hall WA. Meningioma. 2026 Jun 19. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan–. [Accessed September 2026].
2. CoSRH. FSRH CEU Statement: Response to new study by Roland et al (2024). Use of progestogens and the risk of intracranial meningioma: national case-control study. March 2024. [Accessed September 2026].
3. CoSRH. FSRH CEU Statement: Response to new study by Roland et al (2025). ‘Oral contraceptives with progestogens desogestrel or levonorgestrel and risk of intracranial meningioma: national case-control study.’ July 2025.  [Accessed September 2026].
4. CoSRH. CoSRH Statement: Meningioma and Progestogens. June 2026.  [Accessed September 2026].
5. CoSRH. CoSRH CEU Statement: Response to new study by Lundstrøm et al. (2026). Contraceptive Progestogens and Incident Meningioma. July 2026.  [Accessed September 2026].
6. CoSRH. Combined hormonal contraception. October 2023.  [Accessed September 2026].

Written by Dr Toni Hazell.

Disease modifying anti-rheumatic drugs (DMARDs) are widely used to treat inflammatory conditions, some of which are primarily rheumatological (e.g. rheumatoid arthritis), whilst others have their origin in another organ system (e.g. inflammatory bowel disease and psoriasis). DMARDs are started in secondary care; once the patient is stable, prescribing and monitoring is often done in primary care, under a resourced shared care agreement, with regular specialist review. 

In 2017, the British Society for Rheumatology (BSR) and British Health Professionals in Rheumatology (BHPR) jointly published a guideline which significantly changed monitoring frequency, allowing many patients taking a single DMARD to move from monthly to 3-monthly monitoring¹. The most recent BSR update, published in 2025², makes further changes, aiming to individualise monitoring requirements. The drugs covered are apremilast, azathioprine, ciclosporin, hydroxychloroquine, leflunomide, mepacrine, methotrexate, minocycline, mycophenolate, sulfasalazine, tacrolimus and voclosporin.  The long-term prescribing and monitoring of biologic drugs remains the remit of secondary care, and they are excluded from this update. This blog will mainly cover the primary care relevant aspects of the update, rather than actions around the time that the drugs are started. It will focus on adults; the management of children on DMARDs is more complex and shared care is less common. 

The biggest change to the previous guidance is the concept that patients will be divided into those with or without risk factors for toxicity, and the monitoring schedule may vary according to this assessment. This assessment of risk factors should be done by the specialist before starting a new DMARD. Risk factors include CKD ≥3, increasing age, obesity, alcohol consumption, pre-existing liver disease, significant medical comorbidities, a history of DMARD related toxicity, cytopenia and raised liver enzymes in the last six months². The use of other medications which may affect DMARD metabolism or clearance might also be taken into account, A personalised approach to this assessment should be taken and the monitoring schedule in the first six months (during which time prescribing and monitoring is usually still done by secondary care) should be adjusted depending on whether the patient is deemed low, medium or high risk. 

Once a patient is stable on their medication, monitoring may be handed over to primary care, under the auspices of a resourced shared care agreement. For those without risk factors for toxicity, monitoring remains 3-monthly. This may be extended following an individualised risk-benefit assessment (done by the specialist), which may result in monitoring frequency changing to 6-monthly or less, but the interval between monitoring tests should never exceed 12 months. For those who have risk factors for toxicity, monitoring may need to be more frequent, again based on an individualised assessment done in secondary care. Certain combinations considered to be particularly risky (such as methotrexate plus leflunomide) need long-term monthly monitoring. The level of risk factors should be reviewed at least annually in secondary care, at which point the frequency of monitoring might be adjusted up or down. 

It is not the responsibility of the GP to decide on monitoring frequency, but if we are prescribing under shared care then we should be aware of any significant changes to the patient’s health status (such as hospital admissions, changes to other medication or symptoms that suggest toxicity) and it is always reasonable to communicate such information to the patient’s consultant if we think that they might not be aware of the information. Shared care can only take place if there is easy and effective communication between primary and secondary care^2,3; if such communication channels are not open then it is reasonable for the GP to decline to take on shared care, in which case long-term prescribing stays with secondary care³. The full guideline should be consulted for exact details of monitoring for specific drugs, being aware that some have requirements outside of blood tests, notably the need for eye checks for those taking hydroxychloroquine, the frequency of which again varies with risk factors. Shared care agreements should make it clear whether the responsibility for arranging these checks lies with the specialist, the GP or the patient. 

Other than monitoring, there are a few other issues with the GP should be aware of if they are prescribing under a shared care protocol. Patients on immunosuppressive therapy are eligible for a range of vaccinations including influenza (annually), pneumococcus (every 5 years), COVID-19 (eligibility and frequency currently reviewed annually) and shingles (one off set of two doses). The 2025 guidance specifies that, following influenza or COVID-19 vaccination, methotrexate should be ‘withheld for up to two weeks, assuming disease activity and/or risk of flare allows’. Pausing methotrexate in this way increases antibody response to the vaccines but must ‘be carefully balanced against the risk of [disease] flares’. GPs are unlikely to feel that making this risk/benefit assessment is within their skill set and it is hoped that specialists might include this information in clinic letters in the run-up to the flu vaccination season; if that doesn’t happen then practices might want to contact specialist teams to get this information. 

The question of whether to continue or pause a DMARD during intercurrent illness has always been a tricky one and this guideline offers some clarification, saying that in the event of a severe infection, they should be temporarily discontinued until the patient has recovered. A severe infection is defined as one requiring intravenous therapy or admission and the guidance specifies that DMARDs do not need to be paused for ‘minor infections’ – they give the example of an uncomplicated urinary tract infection. However, several DMARDs (particularly methotrexate) have significant antibiotic interactions such that finding a suitable antibiotic can be tricky and may need discussion with the patient’s specialist.

The 2025 update to the DMARD guideline offers the exciting potential that some patients on methotrexate may need to have monitoring only once or twice a year; a significant change to their quality of life from the days, less than a decade ago, when monitoring was monthly for all. It will however take time to embed and for secondary care to get used to making these risk assessments and advising on personalised monitoring. Safety is always paramount for these complex medications and when in doubt, getting advice from the patient’s specialist is always a sensible option. 

References: 

1. Ledingham J, Gullick N, Irving K et al. BSR and BHPR Standards, Guidelines and Audit Working Group. BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs. Rheumatology (Oxford). 2017 Jun 1; 56(6): 865-868.
2. Bechman K, Song K, Abhishek A et al. British Society for Rheumatology Guidelines Steering Group. The 2025 British Society for Rheumatology guideline for the prescription and monitoring of conventional synthetic disease-modifying anti-rheumatic drugs. Rheumatology (Oxford). 2026 Feb 4; 65 (2): keaf522. 
3. NHSE. Responsibility for prescribing between primary and secondary/tertiary care. Jan 2018. [Accessed August 2026].

Written by Dr Toni Hazell

Swallowing difficulty (dysphagia) is a common presentation in primary care. Even when not caused by malignancy, it can be associated with significant morbidity, including malnutrition, dehydration, aspiration pneumonia as well as reduced quality of life. Prompt assessment can facilitate early diagnosis and rule out serious underlying pathology such as oropharyngeal or upper gastrointestinal malignancy.

Classification and aetiology

Dysphagia is broadly classified into four types¹:

Table 1 - The four classifications of Dysphagia

A careful history can give a starting hint as to the type of dysphagia and therefore guide the diagnostic process.

Dysphagia can have gastrointestinal or non-gastrointestinal causes.

Table 2 - Gastroenterogical causes of Dyshagia

Table 3 - Non-gastroenterological causes of Dysphagia

Clinical assessment

History

Key questions include the following^1,9:

• Is the difficulty initiating the swallow or does food stick afterwards?
• Are solids, liquids or both affected?
• Is the problem intermittent or progressive?
• Is there associated weight loss, pneumonia or a history of neurological disease?
• Are there symptoms of reflux, coughing, choking, drooling, hoarseness or nasal regurgitation?

Red flag features include:

• progressive dysphagia
• unintentional weight loss
• iron deficiency anaemia
• haematemesis
• persistent vomiting
• a neck lump
• new-onset dysphagia in older adults.

Examination

Physical examination should include a nutritional assessment, oral cavity examination, cranial nerve assessment, examination of the neck and evaluation for signs of neurological disease and weight loss.

Investigation and referral

NICE recommends urgent endoscopy for all patients presenting with dysphagia³. Additional investigations in secondary care may include:

• barium swallow
• oesophageal manometry
• further imaging to stage any identified malignancy
• biopsies for eosinophilic oesophagitis.

Where endoscopy is normal, but symptoms persist, oesophageal manometry should be considered to identify motility disorders. Patients with suspected oropharyngeal dysphagia should be referred promptly to SALT for specialist assessment and further investigation to identify aspiration or impaired swallow mechanics, and guide management strategies. If malnutrition is suspected, the Malnutrition Universal Screening Tool can be used for assistance¹⁰.

Management

Management should target the underlying cause. As well as any medication or surgery, SALT interventions may include swallow rehabilitation exercises, postural modifications and thickening of fluids or food. Refer early to a dietician if there is a risk of malnutrition.

References:

1. Wolf DC. Dysphagia. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 82. 
2. Puri R, Tian C. Achalasia. [Updated 2026 Mar 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-.
3. NICE. NG12. Suspected cancer: recognition and referral. April 2026. 
4. Perananthan V, Burgell R. Diagnosis and management of eosinophilic oesophagitis. Aust Prescr. 2024 Feb;47(1):20–5.
5. Mona R, Hruz P. Epidemiology of Eosinophilic Esophagitis: Really a Novel and Evolving Disease? Inflamm Intest Dis. 2025 Jan 20;10(1):34-40.
6. BSACI. Eosinophilic oesophagitis. 
7. Kadakuntla A, Juneja A, Sattler S et al. Dysphagia, reflux and related sequelae due to altered physiology in scleroderma. World J Gastroenterol. 2021 Aug 21;27(31):5201-5218.
8. Azer SA, Kanugula AK, Kshirsagar RK. Dysphagia. [Updated 2023 Nov 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. 
9. NICE. Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Aug 2017.
10. British Association for Parenteral and Enteral Nutrition. Malnutrition Universal Screening Tool. 

Written by Dr Toni Hazell

Menopause and hormone replacement therapy (HRT) has become a hot topic in the last few years, with celebrity endorsement for various treatments (some evidence based, others not so much!) and a greater understanding of the multiple ways in which the menopause and perimenopause can present. As well as hot flushes and night sweats (vasomotor symptoms/VMS), symptoms can include insomnia, reduction in energy levels, cognitive dysfunction or ‘brain fog’, low mood, headaches and genitourinary symptoms¹. 

Many women will benefit from the use of HRT, but it is unsuitable for some (for example due to a history of breast cancer), and others prefer not to use it. Alternative options may be bought over the counter or prescribed and as of March 2026 there is one more non-HRT possibility available on the NHS, with the NICE approval of fezolinetant. 

Women who would rather use a herbal option will find plenty to choose from on their local high street or online - isoflavones, soya products, black cohosh, St. John’s wort and red clover are all marketed to treat the menopause. There is some evidence for black cohosh (though use is often limited by adverse effects including constipation and weight gain); there are only poor-quality studies available for other herbal options. Many herbal options have natural oestrogenic activity, and the British Menopause Society (BMS) therefore cautions against their use in women who have had breast cancer. This is not the case for St. John’s wort, which is mentioned in the NICE guidance on menopause as something that may relieve VMS in women who have had breast cancer³. As an enzyme inducer, it does however have many interactions with other drugs that we prescribe, including some such as warfarin for which change in drug levels can have serious implications. Most herbal preparations are not regulated in the same way as prescribed medication, meaning that the amount of active ingredient can vary between products. Women who wish to use herbal treatments for their menopause could be usefully signposted to information from the Women’s Health Concern⁴ and advised to look for preparations which carry the Traditional Herbal Registration (THR) mark⁵. This indicates that the product has been registered with the Medicines and Healthcare Regulatory Agency (MHRA) and meets MHRA standards for quality and safety. A list of preparations with a THR mark is available on the MHRA website⁶ and includes several products used for symptoms of the menopause. 

Menopause-specific cognitive behavioural therapy (CBT) is another hormone-free option, although access on the NHS may vary. It can be delivered face to face or remotely and to an individual or in group sessions³ and has evidence for reduction in VMS severity, stress and insomnia, as well as being particularly useful for those women who have diagnosed anxiety or depression related to their menopause. 

Prescribable options include selective serotonin re-uptake inhibitors (SSRIs), serotonin–norepinephrine reuptake inhibitors (SNRIs), clonidine, drugs which affect the gamma-amino butyric acid (GABA) receptors, fezolinetant and oxybutynin. More information on these is given in the table below^2,3,7,8. We should also remember that all women (whether or not they take HRT) can benefit from lifestyle advice in the (peri)menopause – weight-bearing exercise will reduce osteoporosis risk, exercise in general can improve mood and there is some evidence for the benefits of a Mediterranean diet to improve VMS⁹. 

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We greatly value your commitment to lifelong learning and to maintaining the highest standards of patient care. Your feedback plays a crucial role in helping us improve the CPD products and services we offer. Please could you complete our short RCGP eLearning feedback form, which will take no more than 5 minutes as your insights will directly inform the development of future learning experiences that are relevant, practical, and tailored to your needs as a GP.

References:

1. BMS. What is the menopause? January 2026. [Accessed May 2026].
2. BMS. Non-hormonal-based treatments for menopausal symptoms. November 2025. [Accessed May 2026].
3. NICE. NG23. Menopause: identification and management. April 2026. [Accessed May 2026].
4. WHC. Complementary and alternative therapies. November 2025. [Accessed May 2026].
5. MHRA. The Traditional Herbal Registration (THR) Certification Mark: Guidance for Business. [Accessed May 2026].
6. MHRA. Herbal medicines granted a traditional herbal registration (THR). October 2025. [Accessed May 2026].
7. NICE. TA1143. Fezolinetant for treating moderate to severe vasomotor symptoms associated with menopause. March 2026. [Accessed May 2026].
8. MHRA. Fezolinetant▼(Veoza): risk of liver injury; new recommendations to minimise risk. April 2025. [Accessed May 2026].
9. Kennard A, Lindo FM, Ring M et al. Lifestyle Medicine and Vasomotor Symptoms: An Analytic Review. Am J Lifestyle Med. 2024 Feb 27:15598276241232359.

Written by Dr Dirk Pilat

Tuberculosis (TB) is an infectious disease caused by one of the bacteria in the Mycobacterium tuberculosis (Mtb) complex. It is spread by droplets containing the bacteria released by patients with active TB when they speak, cough or sing. Depending on the environment, the droplets can stay in air for hours¹. It is currently not clear how many people completely clear an initial infection with Mtb, but it is believed that up to 20% of people who come in contact with TB do not become infected (so called resisters)². Of those not resisting infection, the vast majority develop latent TB, but a small subset of patients will develop active disease. Patients with latent TB host a small number of live but inactive TB bacteria, are asymptomatic and cannot spread the infection to others. Nevertheless, 5-10% will develop active TB in their lifetimes³. According to the World Health Organization (WHO) up to one third of the world’s population is estimated to be infected with M. tuberculosis, and the vast majority have no signs or symptoms of TB disease, although they are at risk for active TB disease and for becoming infectious at a later stage⁴. 

The highest incidence of active TB is in the first year after infection and decreases thereafter, with young children most at risk. In people with active lung disease, the most common presentation is a cough, although systemic symptoms such as fever or weight loss are common. In children, the only symptoms of tuberculosis might be poor weight gain and lethargy.

Figure 1 UKHSA TB infographics 2025

In 2026 the United Kingdom’s Health Security Agency (UKHSA) reported the steepest annual increase in tuberculosis cases in England (5490) since national surveillance began, which gives the UK some of the highest TB rates in Western Europe. Wales reported 95 cases in 2024, Scotland 266 and Northern Ireland 86^5,6,7   . While incidence remains the highest in densely populated areas such, rates are rising in the West Midlands, (22.7%), Yorkshire and the Humber (19.2%) and the Southwest (17.7%). The WHO noted that there was a small increase of people falling ill with TB compared to the previous notification period (2022) worldwide, with 87% of notifications coming from 30 high burden TB countries. 

81.9% of TB notifications are for people born outside the UK, with the highest proportion from India, followed by Pakistan, Nigeria and Romania. More than 50% of notified individuals had pulmonary TB. Almost a quarter of patients had had least one co-morbidity such as diabetes, immunosuppression or chronic kidney disease (CKD). 

People from high incidence countries who want to stay more than six weeks in the UK need to undergo pre-entry screening with a chest x-ray: of 700 000 checked through this route, just under 400 people were diagnosed with pulmonary TB^8,9  .

For those diagnosed here in the UK, the UKHSA reports a link between social deprivation and TB, with current or previous homelessness the most common social risk factor (SRF). 

Table 1 Proportions of people aged 15 or more with individual social risk factors (SRFs), England 2024. UKHSA 2026

To improve pick up rates in the community, the ICBs with the highest TB Burden in England have a testing and treatment programme for latent infection that aims to test 25% of new entrants in the UK who arrived within the last five years. NICE believes that primary care has a role to play as well, by suggesting that primary care staff should arrange testing for all vulnerable migrants not previously checked (although this is not part of core funding)¹⁰. 

For patients who present acutely in primary care, consider a diagnosis of active TB for those with cough, fever, night sweats, weight loss, or fatigue in settings with a high incidence of disease, or in patients without symptoms who have epidemiological risk factors such as HIV, particularly from countries with a high incidence¹¹. 

Pathways for referral may vary from locality to locality, but a call to the local TB service will help to avoid confusion and decide whether a referral is urgent or routine.  Some services request that general practice initiates investigations such as chest x-ray, three sets of sputum for acid-fast bacillus (AFB) and TB culture and one sputum for routine culture¹². 

For those patients with suspected TB involving the central nervous system, TB neurological symptoms or those who are systemically unwell, consider urgent admission. 

While TB as a disease is mostly managed by our colleagues in secondary care, we can nevertheless contribute to a lowering of the local infection rate by being vigilant and having a low referral threshold.

RCGP eLearning Feedback

We greatly value your commitment to lifelong learning and to maintaining the highest standards of patient care. Your feedback plays a crucial role in helping us improve the CPD products and services we offer. Please could you complete our short RCGP eLearning feedback form, which will take no more than 5 minutes as your insights will directly inform the development of future learning experiences that are relevant, practical, and tailored to your needs as a GP.

References:

1. Centre for disease control and prevention (CDC). Tuberculosis: Causes and How It Spreads. 2025.  [Accessed March 2026].
2. de Martino M, Lodi L, Galli L and Chiappini E. Immune Response to Mycobacterium tuberculosis: A Narrative Review. 2019. Frontiers in Pediatrics. 7:350. doi: 10.3389/fped.2019.00350
3. CDC. Clinical Overview of Latent Tuberculosis Infection. 2024. [Accessed April 2026].
4. World Health Organization. Latent tuberculosis infection; Updated and consolidated guidelines for programmatic management. 2018. [Accessed March 2026]. 
5. Public Health Wales. Tuberculosis in Wales Annual Report 2024. 2025. [Accessed March 2026].
6. Public Health Scotland. Tuberculosis annual report for Scotland 2024. 2025. [Accessed March 2026]. 
7. Public Health Agency NI. TB still on the increase in Northern Ireland. 2025. [Accessed March 2026].
8. UKHSA. Tuberculosis prevention, England, 2024. 2026. [Accessed March 2026].
9. UKHSA. Tuberculosis incidence and epidemiology, England. 2024. [Accessed March 2026].
10. NICE NG33. Tuberculosis. 2024. [Accessed March 2026].
11. Nathavitharana R R, Jijon D F, Pal P, Rane S. Diagnosing active tuberculosis in primary care. 2021. BMJ. 374 :n1590 doi:10.1136/bmj.n1590
12. Sidhu, Misha. Referrals to ESNEFT (Colchester site) Tuberculosis service. 2025. [Accessed March 2026]. 

Written by Dr Toni Hazell

In an increasingly anti-vaccination world, it should be gratifying to see the phones of clinics and pharmacies ringing off the hook as parents try to get their teenagers vaccinated against meningitis B, but vaccines are best delivered in an orderly fashion rather than due to parental panic. What is going on here? Why do we suddenly have an outbreak of meningitis B, what is being done to control it, and what needs to happen in the longer term? 

Meningococcal disease is caused by Neisseria meningitidis, a Gram-negative diplococcus which occurs in 12 capsular groups – A, B, C, E, H, I, K, L, W, X, Y and Z. Of these, B, C, W and Y are most likely to cause invasive disease in the UK; this usually presents with meningitis or septicaemia, although it can also affect other organ systems, causing pneumonia, myocarditis and endocarditis among other clinical presentations. Meningococcal disease has a high fatality rate (5-10%) and is most common in infants under the age of one, with a secondary peak at age 15 – 19. Survivors may face complications which include limb loss, seizures and loss of vision or hearing¹. 

NHS vaccination against meningitis B (2 doses) is offered as part of the newborn vaccination programme, with a booster at one year. Vaccination against strains A, C, W and Y is given in schools at the age of 142. Vaccination has resulted in a significant drop in the incidence of invasive meningococcal disease in the UK, but the meningitis B vaccination programme only started in 2015², so children over the age of 10 remain unprotected by the NHS. An adolescent meningitis B vaccination programme was considered by the Joint Committee on Vaccination and Immunisation in 2013, but rejected on the grounds of cost-effectiveness, because there wasn’t strong evidence that vaccination protected against meningococcal disease³. Charities are now calling for all adolescents to be vaccinated using a booster programme⁴.

This unprotected cohort includes those starting university, a time where young people will bring together different strains of infectious diseases from around the country, traditionally leading to ‘freshers flu’. Occasionally this mingling of unvaccinated people from different geographic areas has more tragic consequences, as has happened recently in Kent, where there are currently (as of 01.04.26) 21 confirmed cases of meningococcal disease and two fatalities, all with an epidemiological link to a particular nightclub⁵.

Cases of invasive meningococcal disease by epidemiological year, England and Wales 1998-2021. Public sector content available under the Open Government Licence v3.0¹

GPs may be affected by this outbreak in a variety of ways. They might receive requests for vaccination against meningitis B, might see patients presenting for antibiotic prophylaxis, or may have an increased number of patients presenting because they think that they have meningitis, being more aware of possible symptoms due to the press coverage. The latter request would be dealt with in the same way as any presentation of acute illness and a request for vaccination should be dealt with as usual – there is currently no national programme offering NHS vaccination outside of the usual regimen, with the only extra vaccinations being those targeted at students in Kent. Those who missed their adolescent dose of the Men ACWY vaccine can be offered it on the NHS up to their 25th birthday¹, whereas those who missed their newborn dose of the MenB vaccine can only have it up to their second birthday. At the time of writing, most private pharmacies and clinics have run out of vaccine and are adding those who request it to a waiting list. 

Regarding prophylaxis, clinics have been set up locally to the university to offer prophylactic antibiotics to the following groups⁷: 

• All students who live on Canterbury campus.
• All staff who live or work in affected halls of residence.
• Anyone who attended Club Chemistry on 5, 6 and 7 March.
• Close contacts who have been identified by UKHSA.

NHSE have asked that GPs provide this prophylaxis, an unlicensed one-off dose of ciprofloxacin (as per the table below) where students have already travelled home and so cannot collect it from the clinics in Kent⁷. Contractually, the provision of antibiotic prophylaxis in an outbreak is the job of public health rather than the GP; some areas manage this by contracting this work to certain sites (such as an out of hours centre) or funding the GP to do it via an enhanced service or memorandum of understanding. Check what the system is in your area if you’re not sure.  

Ciprofloxacin prophylaxis dose⁶

This is an evolving event, and it remains to be seen what longer-lasting effects this outbreak has, in terms of the behaviour of the public in accessing private vaccinations and decisions on NHS meningitis B vaccination for the missed cohort.

References

1. UKHSA. Meningococcal: the green book, chapter 22. July 2025. 
2. NHS. NHS vaccinations and when to have them. Aug 2023. 
3. UK Parliament. Meningitis: Vaccination. Question for Department of Health and Social Care. Dec 2025. 
4. Meningitis now. No Plan B for MenB.
5. UKHSA. Cases of invasive meningococcal disease notified in Kent. March 2026. 
6. NHS. MenB vaccine for children. March 2024.  
7. NHSE. Outbreak of meningococcal disease linked to University of Kent and the area of Canterbury. March 2026 

Written by Dr Dirk Pilat

The NHS Bowel Cancer screening programme was first rolled out across the United Kingdom in 2006, using the guaiac faecal occult bood test (gFOBT). It was initially only offered to people between 60 and 70, but subsequently extended to 74 (patients over 75 can request tests if they would like to continue testing¹). gFOBT was replaced from 2017 to 2021 across the NHS with the faecal immunochemical test (FIT) and extended to younger people². The stool guaiac test had various issues: a long list of medications could potentially cause false positives, as could certain foods³.  It was also trickier to use, as patients had to apply six dollops of faeces from three different bowel motions to a little paper envelope, reducing the acceptability of the test⁴. The FIT testing kit reduced this complexity and added improved acceptability to just a simple scrape of a testing stick across one faecal sample before adding it to a sample bottle⁵. As FIT uses antibodies to detect the presence of human blood, it is both more sensitive and specific than gFOBT⁶.

The move to FIT caused an increase of screening uptake from under 60% to nearly 70%. Since the introduction of bowel cancer screening in England, the incidence of colorectal cancer in adults fell by 7%. For 2023 to 2024, NHS England:

• Invited 6,969,227 people to take part in screening
• 4,710,330 of them took up the offer of screening, an overall uptake of 67.6%
• 83,112 (1.76%) of the people screened were invited back for further tests
• screening led to 35,039 colonoscopies where at least one high risk polyp was detected
• 5,320 bowel cancers were found – a detection rate of 0.11%⁷.

Across England, Scotland and Wales, eligibility for bowel cancer screening starts at 50 and ends at 74, with biannual invitations. In Northern Ireland eligibility is from 60 to 74⁸.

While the current FIT threshold for referral in England and Northern Ireland is 120 μg Hb/g, Wales has already lowered its threshold for referral to 80μg Hb/g and Scotland has always set its FIT threshold at 80μg Hb/g. In symptomatic patients who had their FIT arranged in primary care, NICE suggests to refer using a suspected cancer pathway referral for colorectal cancer if they have a FIT result of at least 10 micrograms of haemoglobin per gram of faeces⁹. 

In 2026 the threshold in England is being lowered to 80μg Hb/g in a phased rollout that should be completed by March 2028. This will likely increase the amount of positive screening results by 36%, resulting in the detection of an extra 2017 high risk polyps and 663 more bowel cancers. 

While bowel screening is not part of day to day general practice, we still have an important role to play: encouraging to take part in the screening activity by their general practitioner results in a significant increase in uptake¹⁰ and the use of our computerised patient management systems can help here, as we are being notified if patients are not participating. 

We know that more than half of patients having to undergo a colonoscopy experience anxiety around the procedure. This is due to worries about bowel preparation, difficulties with the procedure (embarrassment, pain, possible complications, and sedation), and concerns about the diagnosis - including fear of being diagnosed with cancer¹¹. With the increase in recalls, our patients’ concerns are likely going to lead to an increased amount of people contacting their primary care teams, fearful of going ahead with the examination. We can signpost our patients to a detailed (and reassuring) explanation of what happens on the day of their colonoscopy provided by the NHS.

Reassurance from their primary care team can go a long way to allay a patient’s concerns and support them in partaking in this important screening programme.

References

1.  NHS. Bowel Cancer Screening. 2024.
2. Whyte S, Sun Y. T. ModelHealth and Resource Consequences of Reducing the Faecal Immunochemical Test(FIT) Screening Threshold for Colonoscopy in the NHS Bowel Cancer Screening Programme (BCSP) [accessed February 2026].
   
3. Kaur K, Zubair M, Adamski JJ. Fecal Occult Blood Test. December 2025 [accessed February 2026].
   
4. Strachan H. Wealth of evidence highlights the benefits of bowel cancer screening UK National Screening Committee 2025. [accessed February 2026].
   
5. Cancer research UK. How to collect your FIT. [accessed February 2026].
   
6. Alpha Laboratories. About Faecal Immunochemical Testing - What is a FIT?[accessed February 2026].
7. Strachan H. Wealth of evidence highlights the benefits of bowel cancer screening UK National Screening Committee 2025. [accessed February 2026].
8. Bowel Cancer UK. Bowel cancer screening | About bowel cancer. 2019. [accessed February 2026].
   
9. NICE. Suspected cancer: recognition and referral. 2026. [accessed February 2026].
   
10. Triantafillidis JK, Vagianos C, Gikas A, et al. Screening for colorectal cancer:the role of the primary care physician. European Journal of Gastroenterology & Hepatology. 2017 Jan 1; 29(1): e1–7.  [accessed February 2026].
    

11. Yang C, Sriranjan V, Abou-Setta AM, et al. Anxiety Associated with Colonoscopy and Flexible Sigmoidoscopy: A Systematic Review. American Journal of Gastroenterology. 2018 Dec; 113 (12): 1810–8.  

Written by Dr Toni Hazell

It wasn’t what I wanted in my stocking as a child, but as a full-blown contraception nerd, I’m excited at the December 2025 launch of the new UK Medical Eligibility Criteria for contraceptive use (UKMEC)1. Published by the College of Sexual and Reproductive Healthcare (CoSRH), formerly the Faculty of Sexual and Reproductive Healthcare, the UKMEC is the gold-standard document on contraceptive safety. 

Before getting into the changes, there are some important basics to remember: 

• The UKMEC is about safety, not efficacy, although the document does include an efficacy table (figure 1). 
• Methods are categorised from 1-4, as per figure 2. 1 and 4 are simple – no problem to use or absolutely contraindicated respectively; it’s in the 2s and 3s that your clinical judgment will be important. 
• The UKMEC is one place where 2 + 2 ≠ 4. Two category 2s doesn’t automatically mean an absolute contraindication, but if they are both in the same area, it does signal a cumulative risk and the need for caution. More than one category 3 ‘may pose an unacceptable risk’.¹
• Some methods have different numbers for initiation or continuation, reflecting the different risks attached to starting a method or continuing one that is already being used. 
• If a condition isn’t covered in the UKMEC, that doesn’t necessarily mean that all contraception is safe for use.  Consider seeking advice from secondary care, or, if you are a CoSRH member, submit an evidence request to their Clinical Effectiveness Unit and they will summarise the available evidence for you to use alongside your clinical judgment.²
• The UKMEC is intended to be applied only to contraceptive use. If a woman is getting an extra benefit from her method (for example the management of endometriosis), that may affect your risk/benefit calculation.
  

The key changes are summarised in figure 3.

Chronic Kidney Disease

Regarding CKD, only the most seriously affected are included – patients who either have nephrotic syndrome or are on dialysis. This cohort should not use CHC (due to VTE risk), and DMPA is now UKMEC 3. This is because DMPA is associated with a small loss in bone mineral density, reversible on stopping³ and those with chronic kidney disease (CKD) are already at risk of osteoporosis4. All other methods are a UKMEC 2. 

Multiple sclerosis

The risk from MS is mainly to do with immobility as a risk factor for VTE, so most methods are a UKMEC 1 for those without prolonged immobility, the exception being DMPA, which is a 2, because those with MS have a greater risk of fracture than the greater population. With prolonged immobility, DMPA remains a 2 and CHC is a 3. 

When prescribing hormonal contraception, it is common to be asked about whether it will cause mood changes. Mood alteration is listed as a common or very common side-effect in the BNF for some combined and progestogen only methods^5,6,7 but depression was listed in the previous UKMEC as a category 1. It has been removed from this edition as a category and replaced with a  statement about the effects of hormonal contraception in those with anxiety or mood disorders.

The key points are as follows⁸: 

• There is no clear evidence that any form of hormonal contraception worsens or improves mood. 
• Most evidence is from observational studies, which often have confounding factors, and do not usually focus on women with pre-existing mental health conditions. 
• Some patients do report mood change during the use of hormonal contraception; this may not represent direct causation. 
• Healthcare professionals should explore other possible contributing factors and consider alternative contraception if the patient feels that their mood has been adversely affected by their contraception. 
• Patients with pre-existing anxiety or depression should monitor their mood when starting hormonal contraception. 

There are two sections on multiple risk factors – one for CVD and one for VTE; the section on multiple risk factors for VTE has been updated in this iteration. The UKMEC signposts to NICE for a full list of risk factors but gives examples which include cancer, inflammatory disorders, recent trauma or surgery and being in the postnatal period. Someone with multiple risk factors for VTE is UKMEC 4 for CHC, 3 for DMPA and 1 for all other methods. 

The UKMEC is a long document; it will take time for the changes to fully bed in, but practices will need to decide how they implement it, particularly for those already using contraception. Reviewing all those using DMPA at the time of their next injection, and everyone else at their annual review would be a good start and hopefully we will all be fully up to date with it long before the next one comes along in a decade or so! 

References

1. CoSRH. UK Medical Eligibility Criteria for Contraceptive Use (UKMEC). Dec 2025. 
2. CoSRH. Members’ Evidence Request Service.
3. CoSRH. Progestogen-only Injectable Contraception. July 2023. 
4. National Osteoporosis Guideline Group UK. Clinical guideline for the prevention and treatment of osteoporosis. 2024. 
5. BNF. Ethinylestradiol with levonorgestrel.2025. 
6. BNF. Desogestrel.2025. 
7. BNF. Etonogestrel. 2025. 

Written by Dr Toni Hazell

Chickenpox is a common and unpleasant childhood illness. More than 90% of the population have acquired antibodies to the causative infection (the varicella zoster virus) by the age of 15¹. For many it is a self-limiting illness (often leaving behind scars when scratching cannot be resisted), but there is a risk of significant complications, as listed in the box below. Those at a higher risk of complications include adults, adolescents, children aged under one, pregnant women and immunocompromised people. Around 20 people per year die of chickenpox in the UK³ and there is a risk of neonatal death if a susceptible woman contracts chickenpox in the week before delivery³.

The economic cost to the UK of parents taking time off work to provide childcare to their children with chickenpox is estimated to be over £24 million per year⁴ – the difficulties of taking prolonged time off work for childcare perhaps explains why one survey (the satisfyingly named SPOTTY study⁵ showed that 73% of UK paediatricians surveyed had privately vaccinated their child against varicella. As the author of this blog discovered last year, chickenpox can also wreak havoc if it appears two days before a family holiday!

Until recently, NHS chickenpox vaccination has only been offered to a small group of people. These include susceptible healthcare staff (including non-clinical, e.g. cleaners, porters etc), laboratory staff who work with the varicella virus, and close household contacts of immunocompromised patients, such as siblings of a child with leukaemia, or a child whose parent is having chemotherapy³. For patients who are due to start immunocompromising medication and are susceptible to varicella, vaccination is offered if there is enough time to give the two-dose course before the medication has to be started³.

This will change in January 2026, when universal vaccination begins on the NHS in all four countries of the UK ^6,7,8,9. Details of the programme are as follows¹⁰

• Offered to children at the age of 18 months.
• Given with measles, mumps and rubella as the MMRV vaccine.
• Booster at three years and four months of age.
• One-dose catch-up programme for children born between 1.1.2020 and 31.8.22, who can access the vaccine until the end of March 2028.
• No NHS offer of a single varicella vaccine.
• The MMR vaccine without varicella will no longer be available for the NHS routine childhood immunisation programme, although it will still be available for those who need the MMR vaccine in adulthood. Children who did not have MMR at the usual time and are brought later in childhood should be caught up with MMRV.

So why have the Joint Committee on Vaccination and Immunisation (JCVI), who decided against universal childhood varicella vaccination in 2009, changed their mind? The original decision was made on cost-effectiveness grounds, with an estimate that it would take 80-100 years for the programme to become cost-effective¹¹. The new decision has largely been based on two factors – a review of the prevalence of chickenpox complications, and a change in the way we think about shingles in adults.

The JCVI believe that the cost of chickenpox complications has probably been underestimated, affecting their assessment of of cost-effectiveness of the vaccine. It is likely that many people admitted with complications of chickenpox have had their admission coded with the name of the complication (pneumonia, meningitis, cellulitis etc) but that the code for chickenpox was not added, so the two weren’t linked for the purposes of cost calculation¹¹. The availability of the four-virus MMRV vaccine has also improved the cost-effectiveness calculation, as there is no need for another nurse appointment, over and above the one which would have been necessary for the MMR vaccine.

Another concern in 2009 was that vaccinating against chickenpox would put older adults at an increased risk of shingles, caused by reactivation of the varicella virus. The theory was that those who have had chickenpox in the past have their immunity regularly boosted by coming into contact with children who have varicella (which is infectious during the prodrome, before spots have appeared and children are kept at home) and that reducing chickenpox incidence in children would increase shingles in middle-aged adults. At the 2023 review it was clear that data from the United States (who have vaccinated against chickenpox since 1995) did not support this hypothesis11 – and we also now have the NHS shingles vaccination, which was not offered in 2009.

Vaccine hesitancy remains an issue in the UK, with only 85% of English 5 year olds having had two doses of MMR – uptake in some communities is significantly lower than that¹². It will be interesting to see whether the addition of varicella to the MMR vaccine reduces uptake further, due to unwarranted nerves about multiple vaccine, or whether the benefits of not having to look after an irritable child with chickenpox will encourage people to vaccinate, in turn increasing MMR uptake.

References

1. NICE CKS. Chickenpox. Nov 2023.
2. Oxford Vaccine Group. Chickenpox (varicella). Nov 2023.
3. UKHSA. Varicella: the green book, chapter 34. Sept 2024.
4. LSE. The true cost of chickenpox: at least £24 million in lost productivity a year in the UK. April 2022.
5. O'Mahony E, Sherman SM, Marlow R et al. UK paediatricians' attitudes towards the chicken pox vaccine: The SPOTTY study. Vaccine. 2024 Sep 17; 42 (22): 126199.
6. DHSC. Free chickenpox vaccination offered for first time to children. Aug 2025.
7. Department of health. Chickenpox vaccination to be offered to children in Northern Ireland from 2026. Aug 2025.
8. NHS Scotland. Changes to the Scottish Childhood Vaccination Schedule from 1 January 2026 (phase 2) – introduction of a routine Varicella Zoster (Chickenpox) vaccine. Nov 2025.
9. NHS Wales. New Chickenpox (Varicella) Vaccination Programme in Wales.
10. UKHSA and NHSE. Introduction of a routine varicella (MMRV) vaccination programme for children at one year and at 18 months. Oct 2025.
11. DHSC. JCVI statement on a childhood varicella (chickenpox) vaccination programme. Nov 2023.
12. UKHSA. Evaluating the impact of national and regional measles catch-up activity on MMR vaccine coverage in England, 2023 to 2024.Aug 2024.

Written by Dr Dirk Pilat

Introduction

Venous thromboembolism (VTE) - whether it presents as deep vein thrombosis (DVT) or pulmonary embolism (PE) - is a common presentation in primary care: its annual incidence is 1-2 cases per 1000 population, rising significantly with increased age. In Europe, pulmonary embolism accounts for 8–13 deaths per 1000 women and 2–7 deaths per 1000 men aged 15–55 years¹. Thrombosis UK suggests that 1 in 20 people will experience a VTE in their lifetime². NHS Resolution reports that from 1 April 2012 until 31 March 2022 it documented 687 closed claims relating to VTE injuries across the clinical negligence indemnity schemes, with total damages paid of £23,780,179³. 

Significant risk factors such as major surgery, prolonged immobilisation, and major trauma account for approximately 20% of all venous thromboembolism episodes, though the commonest strong persistent risk factor is active cancer, accounting for approximately 20% of incidents. Table 1 lists persistent and transient risk factors for VTE. 

Table 1: Khan F, Tritschler T, Kahn SR, Rodger MA. Venous thromboembolism. The Lancet 2021 Jul; 398(10294): 64–77.

Signs and symptoms

Patients with a deep vein thrombosis can present with leg pain (80–90% of patients), swelling (80%), localised tenderness on palpation (75–85%), prominent collateral superficial veins (30%) and redness (25%). 30% - 60% of patients presenting with a proximal (above the knee) DVT already have a silent pulmonary embolism. A review paper from Canada described that the majority of symptomatic episodes of lower extremity DVTs start in the distal veins, with symptoms being uncommon until there is involvement of the proximal veins. They reported that in a consecutive series of 189 outpatients with a first episode of venographically diagnosed DVT, where symptoms were all distal, 89% had proximal thrombi⁴. Upper extremity deep vein thrombosis (UEDVT) – arising in the brachial, axillary or subclavian veins - is thought to account for about 10% of all DVTs⁵.

Pulmonary emboli often present insidiously and often without the classic triad of pleuritic chest pain, shortness of breath and hypoxia. There are a large number of case reports showing patients complaining of nagging symptoms for weeks before succumbing to pulmonary embolism, with 40% of these patients being seen by a physician in the weeks prior to their death⁶. A retrospective cohort study from 2016 showed that 25% of patients with a PE presenting in primary care had an average delay of 15.7 days to diagnosis⁷. Table 2 lists the range of symptoms that the NICE CKS suggests point towards a PE.

Table 2: When to suspect pulmonary embolism from NICE CKS Pulmonary embolism 2023.

Diagnosis

The National Institute for Health and Care Excellence (NICE) updated their recommendations for the diagnosis and management of VTE in 2023. It suggests that patients with symptoms that might indicate a DVT should be examined and accessed via a 2 - level Wells Score. If the Wells score is 2 or above, these patients should be offered a proximal leg vein ultrasound scan, with the result available within 4 hours if possible. If the scan is negative, a D-Dimer should be arranged. For those patients that can’t access a proximal leg vein ultrasound scan within 4 hours, offer a D‑dimer test, then interim therapeutic anticoagulation and a proximal leg vein ultrasound scan with the result available within 24 hours. For those patients with a Wells score of 1 or less, arrange a D dimer test with the result available within 4 hours, or, if the D dimer test result cannot be obtained within 4 hours, offer interim therapeutic anticoagulation while awaiting the result. If the D-Dimer test is positive, arrange an ultrasound and add interim anticoagulation if not already started (see Table 5) 

Table 3: Recommended workflow for suspected DVT. NICE 2023

For people who present with signs or symptoms of a PE, arrange a physical examination, take a medical history and offer a chest x-ray (if available in your setting) to exclude other causes. If, after assessment and investigations, the clinical suspicion for a PE is low and other diagnoses are more likely, consider using the pulmonary embolism rule–out criteria to help determine whether any further investigations into a PE are necessary. This questionnaire has not been validated for people with COVID-19.

If a PE is suspected, the 2 level PE Wells score (see table 6) should be used.

If a patient scores 4 or more, NICE suggests a range of different imaging options arranged in secondary care, with anticoagulation to be initiated depending on the outcomes.

If the Wells score is 4 or less, NICE suggests D-Dimer testing with the result being available within 4 hours, or interim anticoagulation if this can’t be arranged. If the D-Dimer is positive, imaging will have to be arranged⁸

Table 4: Recommended workflow for PE. NICE 2023

Table 5: Recommendations for anticoagulation for suspected/confirmed VTE. NICE 2023

In day-to-day practice every locality will have their own protocols and referral pathways for the management of suspected VTE in the community. Nevertheless it is important to remember that patients who score 1 or below on the DVT Wells questionnaire, should still have a D-Dimer test. This was highlighted by a case that a coroner shared with the RCGP, in which a patient tragically died four weeks after an initial assessment for calf swelling; while the Wells score was applied, the patient did not have a D-Dimer. The patient then developed respiratory symptoms and was seen by various healthcare practitioners over a 4 week period before suffering a cardiac arrest caused by a large PE.

The vast majority of patients with VTEs are being expertly managed in cooperation between primary and secondary care. General practitioners are experts in managing diagnostic uncertainty - an inevitable part of their profession - and VTE presentations can certainly can test this vital skill. Acknowledging the broad scope of symptoms and subsequent use of the local pathways for VTE can nevertheless increase the pickup rate further, improving the safety of our patients.

Table 6: Two-level PE Wells score. NICE 2023 Venous thromboembolic diseases: diagnosis, management and thrombophilia testing.

References

1. Khan F, Tritschler T, Kahn SR, et al. Venous thromboembolism. The Lancet . 2021 Jul; 398 (10294): 64–77.
2. Thrombosis UK.
3. Venous thromboembolism. NHS Resolution. 2023.
4. Kearon C. Natural History of Venous Thromboembolism. Circulation. 2003 Jun 17; 107 (90231): 22I-30.
5. Ageno W, Haas S, Weitz JI, et al. Upper Extremity DVT versus Lower Extremity DVT: Perspectives from the GARFIELD-VTE Registry. Thrombosis and Haemostasis. 2019 Jun 10; 119 (08): 1365–72
6. Safi M, Tajik Rostami R, Taherkhani M. Unusual presentation of a massive pulmonary embolism. J Teh Univ Heart Ctr 2011; 6( 1): 41-44.
7. Walen S, Damoiseaux RA, Uil SM, et al. Diagnostic delay of pulmonary embolism in primary and secondary care: a retrospective cohort study. British Journal of General Practice. 2016 Apr 25; 66 (647): e444–50.
8. National Institute for Health and Care Excellence. NG158 Venous thromboembolic diseases: diagnosis, management and thrombophilia testing 2023.