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Hot Topics Blog

COURSE PREVIEW - Hot Topics GP Update Course Autumn 2019

Simon Curtis - 22 Aug, 2019

The Hot Topics GP Update course is a fun, inspiring and informative day packed with learning points to take away to use in practice. We make it easy for you to maintain focus on the day by keeping our presentations short, sharp and focussed with lots of opportunity for interaction, including using live Q&A polls with your smartphone. We use clinical cases weaved in to bring the literature and guidelines to life. All the material is 100% independent and free from any external influence, and all our presenters are NHS ‘coal face’ GPs just look you.

All the presented material will be completely new compared to Autumn 2019.

All delegates on the course will receive:

  • The detailed 350 page Hot Topics paper book summarising all the recent literature for you and packed with Keep it Simple Summaries, learning points and quality improvement ideas to take away 
  • A longer digital version of the book including even more Hot Topics, that you can download or browse online 
  • The digital course book is instantly searchable and hyperlinked to all the references & patient resources
  • The NB Medical App, across which you can access the full content of the digital course book or just the Keep it Simple Summaries (KISS)
  • Pre and post course MCQs to assess learning
  • The webinar version of the course so that you can revise and see the material again
  • The personal email address of the presenters of the course for post course follow up questions

Topics that we are likely to cover on the Autumn 2019 courses include:

  • Cardiovascular medicine
    • Primary prevention in older people
    • What do the evidence and guidelines tell us about managing CV risk in older people, including use of BP lowering medication and statins
    • Hypertension, an overview of the NICE 2019 guideline & it’s key changes
    • Heart failure, including the common heart failure with preserved ejection fraction
  • Prescribing Hot Topics
    • Loop diuretics, how should we use them in practice?
    • New concerns & restrictions regarding quinolones 
    • NSAIDs risks and gastroprotection, and do coxibs have a role?
    • In England only, the new 2019 QOF prescribing quality improvement domain
    • Medical cannabis: what do GPs need to know?
  • Mental Health
    • Depression in children and young people, new NICE guidance and management options for primary care
    • Treatment resistant depression
    • Insomnia…if not benzos or zopiclone, then what next?
  • Respiratory
    • COPD: NICE 2019 guidance on management, treatment of exacerbations & should management be guided by eosinophil counts?
    • Asthma: BTS/SIGN 2019 guidelines update
    • Chronic cough, how should we manage it?
  • Women’s Health
    • Contraception update, including tailored pill taking
  • Infections
    • New NICE/PHE antibiotic guidance
    • Complicated UTIs
    • They’re back: pertussis, measles and mumps
    • Vaccinations update
  • Neurology
    • Suspected neurological conditions, cases based on NICE 2019 guideline
  • ENT
    • Vertigo, and differentiating peripheral from central vertigo
  • Cancer
    • Cases based on recent papers on colorectal cancer and FIT tests, myeloma and LUTs and prostate cancer
  • Thyroid
    • Subclinical hypothyroidism, new practice changing research & guidelines
    • Thyroid, fertility and pregnancy
  • Gastroenterology
    • Chronic diarrhoea, how should we investigate it?
    • Gilbert’s syndrome, what are the clinical implications?
  • Abnormal investigations
    • Making sense of inflammatory markers
  • Smoking
    • Latest evidence on e-cigarettes and vaping, what should we be advising our patients?
  • Musculoskeletal
    • Polymyalgia and GCA
  • Miscellaneous Hot Topics cases to end the day

As ever, we like to keep it practical and pragmatic whilst also considering many of the broader issues and challenges we face. And we like to have a laugh too!

We look forward to seeing you!

Simon, Neal, Siobhan, Kate, Zoe, Ahmed, Rob, Stephanie, Sarah, Duncan, Mark and Will

The NB GP Team


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Green with Asthma

Neal Tucker - 15 Aug, 2019

How can I be more green? Cycle to work? No more steak? Stop my inhaler…?

Many us of are becoming more carbon-conscious. Whether this means cutting down on red meat (turns out the vegans were right all along), using the car less (until we can actually afford a Tesla), or camping in a soggy British field for the summer holiday instead of getting on a plane (which may actually be preferable to managing small children in an enclosed space at 10,000ft), there is more that most of can do.

But if you have asthma, how should you react to the recommendation in the latest BTS / SIGN guideline on asthma management to use inhalers with a low-global warming potential? BTS and SIGN are not alone here. In April NICE also made similar recommendations. While it made the headlines, it seems to have passed by clinicians leaving many patients somewhat confused.

Context is useful. BTS / SIGN quotes that 3.5% of the total NHS carbon footprint comes from metered dose inhalers. Sounds small but that’s significant for such a tiny part of all the NHS does. MDI devices were banned from using CFCs in the early 2000s, replaced with HFAs. Turns out that these hydrofluoroalkane propellants also have “high global warming potential”. A single inhaler has the same carbon footprint as driving a car for 180miles. Of course there are simple alternatives – dry powder inhalers have 25x less carbon footprint than MDIs or breath-actuated inhalers.

So, what’s stopping us? The biggest barrier is familiarity. Clinicians have spent decades with the good old “blue inhaler” and when we talk about treating asthma most of us describe using a MDI. Likewise for patients, even with no personal history of asthma or inhaler use, consider this to be what an inhaler to be. The image of an asthmatic squeezing their inhaler, its iconic puff, the sharp breath in, is ingrained in pop culture. 

However, patients can be flexible – most would be happy to try something different and given the relevant information many would be doubly keen to. So now is the time for us to educate ourselves a bit more on the plethora of options at our fingertips. The good news is while there is a confusing array of different inhalers on the market, there are also excellent resources to help. 

www.rightbreathe.com is a fantastic UK website produced by a handful of London pharmacists and doctors. It has details of every available asthma and COPD inhaler in the UK, allows each searching for type (e.g. short-acting beta agonist, LABA/LAMA combination, etc.) and has handy instructional videos for patients (and clinicians if you wish).

NICE has produced a useful PDF patient decision aid (which only comes in at 14 pages in total, pretty restrained for NICE) which has a neat flow chart for clinicians and patients to guide on which type of inhaler might be best for them, with clear information about the relative merits of each type, including a discussion on the environmental impacts of each.

For further information, Asthma UK is a veritable font of knowledge with lots of instructional resources for ensuring good inhaler technique.

Blanket switching, of course, is not recommended. Dry powder inhalers will not be appropriate for everyone, particularly patients who cannot take a quick, deep breath in for 2-3 seconds. And while there is a small chance it could alter a person’s asthma control on a reassuring note other countries have much lower rates of MDI use – 10-30% in Scandinavia versus 70% in the UK – and their asthma outcomes are certainly not worse than here. Time for a change?


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Time to rationalise our use of inflammatory markers

Rob Walker - 1 Aug, 2019

I can still remember my first weekend on call as a surgical house officer - rushing around on the morning post-take ward round when a radiology request card was thrust in my hand, and I was sent like a lamb to the slaughter to the on-call radiologist to request an ultrasound for a patient with suspected cholecystitis. This particular radiologist was well known to have a penchant for making new house officers crumple if we dared request out of hours radiology without the most water-tight argument. ‘HOW WOULD THIS INVESTIGATION CHANGE YOUR MANAGEMENT?’ came the well-rehearsed mantra. Well, frankly I had no idea; I’d only been a doctor for a week and had no clue if the surgeons were planning to operate over the weekend or not, so I was duly sent packing back to my senior to get more information.

Brutal though that first encounter was, it did teach me an important lesson - knowing what test to use, when and for what conditions is a crucial skill in medicine, particularly in General Practice. A really excellent study in the July BJGP brought into sharp focus an area where there is wide variation in practice, namely the use of inflammatory markers for diagnosis. Inflammatory marker testing in primary care is rising every year, but little is known about whether this is helping diagnostic accuracy or simply generating a cycle of further testing for little gain. Increasingly it appears we are doing CRP and ESR to try to rule out serious disease and reassure us and our patients, but is this helping? Well, this was one of the questions posed by an excellent cohort study in the July 2019 BJGP. The authors looked at a large cohort from the CPRD from 2014, including just under 160,000 patients that had inflammatory marker testing (ESR, CRP or plasma viscosity) and just under 40,000 matched controls who did not have testing. Those with known cancer, auto-immune disease or chronic infection were excluded and the authors then reviewed the numbers of participants who developed serious disease (including cancer, auto-immune disease and infections) in those with raised or normal inflammatory markers. Much of the testing was for non-specific symptoms (with tiredness being one of the commonest reasons for testing) and the results showed that of the ~28% who had raised inflammatory markers, 85% of these had no significant disease (i.e. 85% were false positives). The study went on to confirm that these false positives led to huge numbers of unnecessary further tests, appointments and referrals. The authors estimated that for every 100 inflammatory marker tests done, it would generate ~24 false positives which would lead to 71 further GP appointments, 23 further blood tests and 2-3 referrals, all for very little benefit.

The other issue the study confirmed is that inflammatory marker testing showed very poor sensitivity for serious disease, meaning they are generally not suitable as rule-out tests either. I was particularly interested in those with a cancer diagnosis - based on the results 21/1000 tested had cancer with 10 having positive inflammatory markers and 11 negative results i.e. doing a CRP/ESR added no value to diagnosis of cancer, and in those with negative results there is a real risk of delayed diagnosis by giving us and our patient false reassurance. The one exception to this would be suspected Myeloma - previous research in the BJGP in 2018 showed that a combination of a normal Hb, ESR and calcium was sufficient to rule out myeloma in the vast majority of the cases, but this is clearly the exception not the rule with inflammatory marker testing.

The message from this research seems quite clear - injudicious use of inflammatory marker testing for non-specific symptoms is likely to cause more harm than good. It will generate huge numbers of false positives, and subsequent unnecessary onward testing and appointments, as well as false reassurance in some patients with normal CRP/ESR who do have serious underlying disease, and a risk of delayed diagnosis. ‘HOW WOULD THIS INVESTIGATION CHANGE YOUR MANAGEMENT?’ - a question we should all be asking when considering use of inflammatory marker testing in primary care.


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