_ RCGP Learning

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
• Adherence
• 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

The EKU Hot Topics and EKU Journal Watch pages also include many resources on asthma. Topics include:

• 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

References:

(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. [2016]. 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:

1. 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.
2. 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.
3. 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:

EKU 16: Diagnosis & Management of Irritable Bowel Syndrome in Adults

References:

(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.

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

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

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

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

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

How will this learning/improved knowledge from GP SelfTest impact upon your practice?
What have you done differently with your improved learning?
What impact will your improved learning have on your patients?
Has it helped you with a Quality Improvement Activity (QIA)?

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

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

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

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

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

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

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

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

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

Sexual Health in Primary Care – 2 CPD credits

Contraception – 1 CPD credit

HPV - the essentials – 0.5 CPD credits

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

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

EKU4 – Managing of genital chlamydia trachomatis infection

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

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

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

References:

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

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

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

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

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

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

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

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