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Midfacial Segment Pain

Rob Walker - 16 Aug, 2018

Boris comes to see you in your afternoon clinic. He’s 54 and you don’t see him very often and he’s had a bit of stress at work lately. He’s had some aching pain around his nose, cheeks and under his eyes for a few months, with a blocked and occasionally runny nose. The pain is a nuisance and he finds it distracts him sometimes, but he’s been able to continue to work and function as normal. He is slightly tender over the cheeks/maxillary sinuses. Diagnosis? Well I suspect many of us would be thinking this is likely to be rhinosinusitis….however, we may well be wrong in this assumption, as I found out having read a very useful ‘Practice Pointer’ review in the BMJ on orofacial pain

I find that one of the great joys of General Practice is that if you keep your eyes open, you cannot help but learn something on an almost daily basis, whether it be from patients we see, colleagues we chat to, or things we may read. The BMJ review above rather caught my eye and there were a couple of very useful learning points for me, notably me learning about a new clinical syndrome I’d never heard of before! The infographic BMJ Visual Summary - Orofacial Pain gives a very good summary of the article. One of the focusses of the article was that bilateral ‘sinus’ pain is often NOT due to rhinosinusitis; acute bacterial sinusitis can obviously present with pain, but it is usually unilateral and associated with URTI symptoms and fever. Chronic rhinosinusitis however, rarely presents with pain - in fact pain is present in only ~10% of patients with chronic rhinosinusitis. A European Position Paper on rhinosinusitis suggests that the vast majority of patients presenting to ENT clinics with sinogenic facial pain do not have rhinosinusitis and as many as a third actually have 'midfacial segment pain’.

So, what in Osler’s name is 'midfacial segment pain’? Well, it appears to be another of those classic conditions that simply describes the presenting symptomatology in more ‘medical’ language (remember palmar erythema….’red palms’!). Midfacial segment pain is a poorly understood and poorly recognised condition causing pain with similar characteristics to tension headache, but in the area of the midface, nose, cheeks, retro- and peri-orbital regions. Nasal blockage can be present. There may be tenderness or hyperaesthesia over the cheeks. The aetiology is unknown.

So what are we going to do to help Boris? Well, in the past I would have been advising steroid nasal sprays and possibly nasal douching….however I now wonder if he may have midfacial segment pain. The BMJ article and European Position paper suggest a trial of amitriptyline 10-20mg nocte for 6 weeks, and if successful to continue treatment for a minimum of 6 months before weaning off. Boris seems happy to give the amitriptyline a go and you suggest a 6 week review.

We really look forward to seeing you in our upcoming Autumn/Winter Courses - we’ve got loads more learning points for you, so why not sign up now! 

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Tips for New Doctors

Ahmed Rashid - 9 Aug, 2018

It’s a rite of passage in medicine to be absolutely terrified on your first day as a doctor. I distinctly remember how my hands were shaking when I signed a prescription for the first time, and the great care I took when making my first entries into clinical notes. As the learning curve is so steep, it can be easy to forget just how challenging those first days and weeks actually were.

When I was a medical student, the advice I got about my first day came mostly from conversations in the doctors’ mess, hearing about the mistakes, experiences, and regrets of junior doctors. I lapped up their pearls of wisdom, hoping desperately that I would survive the escapades that they had somehow managed to navigate. But the era of doctors’ messes seems to have passed, and many newer hospitals don’t even have such spaces. 

So where do new entrants to the medical profession seek this informal advice nowadays? Social media, of course! For the millennial generation, the smartphone is all you need for everything, and career advice is no different.

Hashtags (a word or phrase starting with the ‘#’ symbol and continuing without spaces) are an important part of many social media platforms, and allow users to search for information and to follow or contribute to discussions on particular topics. Many hashtags that link together conversations between doctors have emerged, fostering a sense of community. One such hashtag is #TipsForNewDocs, which was devised to provide advice to newly qualified doctors who are preparing to embark on their first clinical roles.

In a recent study published in Medical Education, our team analysed all tweets posted using #TipsForNewDocs over a 48 hour period in early August 2016. We found that despite their brief and often comical nature, these tweets provided meaningful advice, on topics as diverse as how to refer to specialists, how to behave towards non-medical colleagues, how to look after yourself, and how to recognise sick patients. There was also a clear pattern of socialisation, with lots of tweets giving advice on how to fit in to the medical profession, including for example, advising on subjects that it’s OK to laugh at (almost everything!).

One of the most striking findings for me, though, was the diversity of backgrounds of those tweeting on this topic. Unsurprisingly, many junior doctors, GPs, and hospital consultants were posting. But advice also came from nurses, pharmacists, allied health professionals, paramedics, and other professional groups. Most promisingly, there were also a large number of tweets from patients and members of the public. 

As well as new foundation doctors on wards, there are also a whole load of new GP registrars and newly qualified GPs starting work at this time of year too. So if you have any advice for them, tweet using #TipsForNewGPs to let them know all those things you wish you’d known when you were starting out in the formidable world of general practice.

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TSH and Pregnancy: Treat the Test or the Patient?

Simon Curtis - 23 Aug, 2018

Susan is newly pregnant. She had some thyroid tests done earlier this year and was diagnosed with subclinical hypothyroidism. Her TSH was 6 mIU/ml with a normal thyroxine and negative anti thyroid antibodies. She has read in a forum online that she needs to be treated with thyroxine but she is worried about taking medication when pregnant. What do you advise her?

Hypothyroidism has long been associated with miscarriage, preterm delivery and other adverse outcomes in pregnancy. Standard pre-conception advice for women with hypothyroidism is to check TFTs before conception, ensure they are in the euthyroid range and to escalate the dose of thyroxine as soon as possible in pregnancy NICE CKS 2016. Guidelines vary locally, but increasing the thyroxine dose by 30% as soon as pregnancy is confirmed is typical. TSH reference ranges differ in pregnancy, and the recommended upper limit of TSH is 2.5 in the first trimester and 3.0 mIU/ml in the subsequent trimesters BJGP2016;66:538. (although a TSH <4 is recommended in the latest 2017 US Guidelines)


Image Copyright: <a href=" / 123RF Stock Photo</a>

So far, so (relatively!) uncontroversial. But what about women like Susan with subclinical hypothyroidism? Do they benefit from treatment as well? This is a big question, as we know that it affects 3% to 15% of pregnant women BMJ2014;349:g4929. Current guidelines advise that all women with subclinical hypothyroidism who are pregnant or intending conception should be treated with levothyroxine BJGP2016;66:538, but what does the primary evidence tell us? When you scratch under the surface a complicated picture for Susan emerges...

Observational studies do consistently show that subclinical hypothyroidism in pregnancy is associated with multiple adverse maternal and neonatal outcomes, but a systematic review in 2016 concluded that the value of thyroxine treatment in preventing these outcomes was uncertain. In 2015 a BMJ uncertainties paper BMJ2015;351:h4726 raised the question: are we over treating subclinical hypothyroidism in pregnancy? 

So, some recently published new evidence is welcome BMJ2017;356:i6865. This was a large cohort study of over 5,000 pregnant women with a TSH of between 2.5 and 10 mIU/L, and they compared women who were treated with thyroxine with untreated women. The results were very interesting. Treated women had a significant reduction in pregnancy loss compared to untreated women, from 13.5% to 10%. However treated women also had higher risks of other adverse outcomes compared to non-treated women, including pre-eclampsia (5% to 6%), pre-term delivery (5% to 7%) and gestational diabetes (9% to 12%). Intriguingly the authors suggest that since the observed benefit of treatment was in preventing early pregnancy loss, treatment may only be needed in the first trimester. The study raises yet more questions and presses the case for an urgent need for the prospective randomised controlled trials that we currently lack to answer them.  

So, what do we advise Susan? Our role, as always, is to facilitate shared informed decision-making and to treat the patient and not the test. We need to repeat the TFTs, explain that subclinical hypothyroidism is associated with an increased risk of adverse outcomes, that guidelines do recommend treatment and to offer her a specialist opinion…but also to explain that there is real uncertainty regarding the outcome of treatment. We should encourage her to do her own research but if she does it is likely that Susan, like me, may then find she ends up ‘better informed but more confused’!

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Q&A Session from Men's Health Webinar

Rob Walker - 2 Aug, 2018

PSA testing and prostate cancer screening

  • What about PSA ratio for prostate cancer screening

PSA ratios are sometimes used by urologists to increase the accuracy of prostate cancer detection before intervention, or for monitoring. However, there is little data to guide it’s use in screening in primary care or when we should refer, and none of the guidelines recommend it’s use currently for us

  • Is it OK to do a PSA after digital rectal examination (DRE) - does DRE increase PSA levels?

This is not mentioned in the Prostate Cancer Risk Management Programme (PCRMP) so we can’t answer that question unfortunately; however the PCRMP does specify that before a PSA test men should not have:

  • an active urinary infection (PSA may remain raised for many months)
    • ejaculated in the previous 48 hours
    • exercised vigorously in the previous 48 hours
    • had a prostate biopsy in the previous 6 weeks

  • What is the evidence for doing a DRE?

A good question and the answer is there is limited evidence on the subject. A recent systematic review in the Annals of Family Medicine concluded there was limited evidence to support the use of DRE in primary care for prostate cancer screening, however the studies reviewed were of poor quality so it’s difficult to draw any conclusions from it. The PCRMP recommend that DRE should be offered along side PSA testing

  • Further patient information and support -

Our thanks to Mr Chris Booth, a urologist who sits on the clinical advisory board of the charity Tackle Prostate Cancer, who contacted us after the webinar to signpost us to the Tackle website. Tackle supports patients with prostate cancer and their families as well as raising awareness on the subject; their website can be found here

Overactive Bladder

  • What should patients record in a bladder diary?

Here is a link for a free download bladder diary with all the information needed - Click here

  • Should we use an IPSS (International Prostate Symptom Score)?

If we think there are voiding symptoms (i.e. outflow obstruction - hesitancy, poor stream, straining) then doing an IPSS is useful, because as we mentioned in the webinar older men will often have overlap symptoms of OAB and outflow obstruction. A score of ≥7 is considered to be significant. Link here for IPSS

  • For mirabegron use, how frequently does BP need to be monitored initially and how long should BP be monitored for?

Another good question to which it is difficult to give a clear answer as the guidance is somewhat vague! The MHRA (and BNF) recommend that when prescribing Mirabegron BP ‘should be measured before starting treatment and monitored regularly during treatment, especially in patients with hypertension’ - as is often the case sensible primary care interpretation is required!

  • How do you distinguish between idiopathic nocturnal polyuria and bladder outflow obstruction or OAB?

Based on the bladder diary if older patients pass more than 35% of total urinary output at night (and younger ones >20%) with no apparent cause then the patient may have idiopathic nocturnal polyuria

  • Where can I read about bladder retraining? Any good Patient information leaflets?

Yes - excellent leaflet from the British Association of Urologists here.

Erectile Dysfunction

  • Can we prescribe PDE5 inhibitors on the NHS?

I thought I ought to clarify this question as a number of people asked about it. Generic sildenafil can now be prescribed without restriction on the NHS, however branded Viagra and all the other PDE5 inhibitors (branded or generic) cannot be prescribed on the NHS unless they fulfil the SLS criteria. Full details can be found here from the CKS Dec 2017

  • I think I have heard about specialists using a daily dose of sildenafil for ED?

Personally I have not come across the use of sildenafil for daily dosing, and the usual recommendation is it should be used on a PRN basis, however I have seen low dose tadalafil (2.5mg or 5mg) used on a daily basis on urology recommendations; low dose tadalafil does have a license for daily dosing (but prescribing it on the NHS would be subject to the SLS restrictions)

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