Just a quick reminder that Mr Richard Foon will be talking to us on Wednesday 12th April at the Shrewsbury Club about Incontinence Issues.  This is a huge issue for many of our older female patients and some of the men too so it should be an interesting evening.

My appraisal must be due as I have been on two update days and an evening meeting this week.  I am going to share the depths of my ignorance and some new learning that came my way. Now all I have got to do is remember it!  I hope you find it as interesting as I did

• The recent change in the asthma guidelines, following the National Review of Asthma Deaths (2014) had completely passed me by, with the first presentation being coded ‘suspected asthma’ and treated with a 6 week trial of inhaled corticosteroids. If the individual responds the diagnosis of asthma is made and coded.  Salbutamol moved from first line treatment to rescue treatment.  The idea is that first line treatment is still corticosteroid when the rescue inhaler is used more than three times week, LABA (in a combination inhaler so the patient can’t forget to take their steroid) is the second stage followed by a move to a medium dose inhaled corticosteroid and so on.  Theophylline is back in fashion at Step 4 as an alternative to tiotropium .  The aim is to make sure that people with asthma have normal respiratory function on optimal treatment and it is certainly appealing. There is also the salutary statement to consider: spirometry is wrong 50% of the time!
• The guidelines for patients on TNF-alpha DMARDS should include advice about chickenpox exposure & the increased risk of shingles – DMARDS (the imabs) should be stopped for one month and the patient’s immune status should be checked with antiviral therapy if not immune.

 

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The first update day I went to was at the RCGP and was an update on neurology from a GP perspective.  Talks were variable but all were given by incredibly motivated people all trying to do a good job for patients.  There were a number of take home messages that might be interesting to you:

A really useful website, supposedly for patients but probably better for doctors is www.neurosymptoms.org.uk

 

Dementia

• The incidence of dementia is falling worldwide, but the prevalence is rising because we are living longer.  Late onset dementia is a random event and not genetically predetermined
• Assess mood in everyone presenting with subjective memory loss – many are depressed or anxious reducing their inability to process information.
• Functional Cognitive Disorder (FCD) is an emotional response by individuals with ‘memory perfectionism’ and is due to distractability preventing information from leaving the short-term memory as well as the physiologically inefficiencies of word retrieval that worsen with age and probably have a genetic influence.
• An important discriminating feature of dementia is that symptoms onset is rarely noticed by the patient. Take a collateral history from the informant accompanying the patient. The best test is currently the IQ code questionnaire which is completed by the informant (PDF versions are available on the BGS website).  Self reported scores are not helpful as the ability to complete the questionnaire is more related to intellectual attainment than memory.
• The prodrome of Alzheimers is usually one of irritability and apathy (exclude depression and treat it if it is present)
• Dementia in young people is usually caused by a fronto-temopral disorder and memory tests do not pick these up.
• Do not arrange brain scans as the ‘incidentalomas’ are more common than positive signs of a dementing disease
• Stroke presenting as dementia is rare – thalamic infarct

Parkinsons Disease

The pre-clinical presentation is constipation, depression, hypo-osmia and REM Sleep disorder – these symptoms persist through the disease and can be more distressing than the PD because of the reduction in quality of life.  The disease may be treatable at this stage so refer.

• 1:4 PD patients do not have a tremor
• 80% of people with anosmia develop Parkinsons – is the cause of PD in the gut?
• 90% of people with REM sleep disorder get Parkinsons
• The non-motor symptoms of Parkinsons include dizziness, fatigue, a ‘coat hanger’ headache that includes the shoulders and gut problems, due to decreased transit time which can lead to pseudo-obstruction. Other GI symptoms include dysphagia and consequent hypersalivation,  sweating (poor heat dissipation)
• Pain is a significant non-motor symptom of PD which is often unrecognised
• Sleep disturbance with sudden onset sleep – ask about this, esp if patient is still driving
• Postural instability – test with the patient standing close to the wall so when they fall back they will have support!

The talk on multiple sclerosis was brilliant – from a Canadian associate professor who firmly believes in primary care – not much new but a very clear treatise on the subject and this was followed by a professor from Southampton who gave a talk on sensory symptoms – both say that their luxury item on a desert island would be a tendon hammer to differentiate UMN (central) and LMN (peripheral) lesions – I’m off to blow the dust off mine!  He is setting up a neurology training course from the GP perspective which is piloting next year, If I find out more I will keep you informed.

The afternoon workshops were on dizziness, transient loss of consciousness  and headaches and although there wasn’t much new stuff, it did serve to clarify things.

• Medication for headaches should be short term, reviewed at 3 monthly intervals and stopped once the headaches are under control.
• Medication overuse headaches occur predominantly in migraineurs.
• Ask about a history of travel sickness in young people with headaches, if present the headaches are likely to be migraine.
• Beware the MRI scan – 7% of young fit recruits to the German airforce had abnormalities on their MRI scan which were not related to any clinical issue.
• Candesartan can be used as a first or second line treatment for migraine starting at 8mg and increasing after 2 weeks to 16mg, it has a low incidence of side effects but shouldn’t be used in pregnancy or pre-conceptually (Butterbur or CO-enzyme-Q may be equally effective according to the Canadian Medical Association  Journal but none of the neurologists mentioned that!)
• Venlafaxine is useful for migraine with headache.
• Topiramate is also known as ‘toximate’ because of the high incidence of unpleasant side effects.
• Migraine without headache (also known as acephalgic migraine) is more common in older patients who present with a visual aura, hemiparesis and symptoms occurring in clusters or flurries. Most are diagnosed on a stroke unit

There is a good summary of dizziness in the BMJ

How many doctors out there know that you should stop metformin when someone is acutely unwell, know about nephrotoxic agents and regularly monitor renal function. I certainly knew I should but never seem to see the patients in time.  On Saturday, I heard about the Salford initiative on acute kidney injury but did’t realise at the time that it was initiated in Scotland and borrowed by the English (Salford CCG) so credit where credit is due, here is the link to the Scottish Patient Safety Programme website and the Sick Day guidance for patients on drugs that may injure their renal tubules when they become acutely unwell, dehydrated otherwise hypoperfused. This is one for the PDP!

Have a great week!