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Welcome to the Pallant Medical Chambers blog.

Information

We believe that all clinicians have a great need for accurate and up-to-date local clinical information.

We create and nurture excellent working relationships between each chambers and local educational resources, and our members and managers collate this clinical information for their colleagues.

This is then published in a series of networked and interactive online media that our Pallanteers are able to access any time, anywhere.

Ella-One and breast-feeding

This guideline notes that the advice for using this form of emergency contraception whilst breastfeeding has changed. Women should not breastfeed for 5 days after taking Ella-One. They should express and discard milk in that time to maintain production. Alternatives are Levonelle (with no breast-feeding restriction) and the copper coil (which can be used from 4 weeks postpartum).

Social Anxiety Disorder

This guideline talks about recognising and managing social anxiety disorder in adults and children. The median age of onset is 13.
Social Anxiety Disorder is common (12% lifetime prevalence), often coexists with other mental health disorders and substance misuse and can have a big impact on schooling, relationships and social functioning.
Many people never seek help and for those that do, they will often wait years before coming forward, so we need to be proactive about looking for it. We also need to provide an environment that allows people to talk to us. Phone calls, or writing could help, or separate waiting areas, for example.
As so often is the case, there’s nothing earth shattering here, but I will summarise the main points.

Identification in adults
Consider using the 2 following screening questions:
• Do you find yourself avoiding social situations or activities?
• Are you fearful or embarrassed in social situations?
If they answer ‘yes’ to either, do a fuller assessment. Consider using a validated tool, such as:
• Social Phobia Inventory (SPIN)
• Leibowitz Social Anxiety Scale (LSAS)
Also ask about avoidance, distress, fear, triggers, view of self, safety seeking measures and functional impairment. Ask about pre and post event processing.

Identification in children
Kids may present differently. They may cry, freeze or throw tantrums in social situations. You may need to explain more when trying to identify the anxiety. NICE gives suggested wording, but it is basically giving typical triggers and symptoms in simple language.
Kids may find it hard to talk to you, so suggest talking through their parent, or writing or drawing.
There are paediatric versions of the SPIN and LSAS tools available.

Treatment
• First-line in both adults and kids should be referral for CBT.
• If they refuse, explore why. Offer supported self-led CBT (they don’t explain how to access this or specific resources, though advise that ‘a CBT based self-help book’ should be used.
• If they still refuse, offer medication. Start with an SSRI (they advise escitalopram or sertraline, then fluoxetine or paroxetine), then SNRI (venlafaxine), then a MAOI.
• If one intervention doesn’t work, combine pharmacological and psychological treatments.
• Do not use medication in kids.

Zoely – A new Combined Oral Contraceptive (COC) pill

This guideline advises that ‘Zoely’, a new COC, is now available. It is a little different to other pills in having 24 days of active pills and only 4 days of inactive pills, giving a 4 day pill-free interval. It adds to our contraceptive armoury, rather than being otherwise very different. I’ve summarised the main things to know, but always advise women to read the leaflet. The missed pill routine is different to other pills.

Risks – as for other COC. Use the UKMEC Criteria to judge safety of use.
Efficacy - similar to other pills.
Cost – £5.50 a month (other pills range from £0.63 to £8.39)
Side-effects - similar to other pills. The main reasons for stopping are weight gain, acne and bleeding patterns. You can advise women that break through bleeding is likely to settle in time.
Advantages – may improve acne, lighter withdrawal bleeds compared to some pills and 30% of cycles will have an absent bleed.
Starting routine – as for other COC pills.
Missed Pill Routine – this varies depending on where in the pack the woman is. If she is more than 12 hrs late, she needs to do something, so she should read the leaflet to see what to do. It’s too detailed to summarise here, but you can have a quick read of that bit of the guideline.

Feverish Illness in Children

This guideline is an update of the 2007 version. There is nothing mind boggelling here, but it’s worth printing out a new version of the ‘traffic-light’ sheet.

They have handy ‘parent information sheets’ that you can print out too. The sections on ‘Caring for your child at home’ and ‘Seeking further advice’ are useful for safety-netting.

So what’s changed? I’ve summarised the most important changes or things that haven’t changed but are good to remember:
• Tachycardia has been defined and age specific ranges given (see the new ‘traffic-light sheet’ (new).
• Duration of fever shouldn’t be used as a risk factor, but remember Kawasaki disease if they’ve had fever for over 5 days (new).
• Remote Assessment. If you are assessing a child over the phone, any red features should prompt a face to face review within 2 hrs (not new).
• Antipyretics. The advice before was ‘only 1 at a time’. Did anyone do this? Anyway, they’ve now advised that parents can add in the second agent if the first alone isn’t controlling symptoms (new).
• Red Features. This is stated as being for secondary care, but probably applies to us too. If you have a child with ‘red features’ and give them antipyretics, don’t judge severity of illness by a fall in temperature, or by the lack of a fall. All these kids need a full reassessment regardless (new).

Sexually Transmitted Infections in Primary Care

This isn’t a guideline really, but an excellent booklet (I can’t link the actual booklet, but it’s easy to find on the above link). It is a one stop shop for all you need to know about STDs and sexual health. There’s far too much to summarise, but I would encourage you to spend 10 minutes scrolling through, so that you know what it covers. You can then refer back to it when you need.

ICDs, Occipital stimulation for Migraine and Treatment of Vertebral Fractures

Subcutaneous ICDs
The first guideline advises that subcutaneous ICDs can be used. Traditional ICDs have leads placed transvenously, which is more complicated and requires a GA. Subcutaneous ICDs seem to be safe and effective, though so far data is on short term use. A nice to know detail only!

Occipital Stimulation for Migraine
This guideline advises that occipital nerve stimulation can be used for intractable chronic migraine. There isn’t enough good data to be sure that it is effective, though some small studies suggest that it may be. A neurostimulator is placed subcutaneously and leads run to the level of the occipital nerve, so it doesn’t sound the simplest of procedures. Worth being aware of as patients may ask about it…

Percutaneous Vertebroplasty and Balloon Kyphoplasty for Vertebral Fractures
This guideline isn’t talking about new procedures, but they do seem to go in and out of fashion. These procedures do both work and also confer a mortality benefit. The main thing for us to be aware of is that the earlier these patients are treated, the better (ideally around the 6 week mark, when the pain should have settled if it’s going to, but before the fractures have fully healed). However, patients must already be on ‘optimal pain relief’, which is tricky to achieve by 6 weeks and my experience of these patients is that they often present quite late. As these procedures are normally organised by the pain clinic they’ll also have to wait about 3 months to get seen. So all in all, nice to know it works, but not very practical.

Omalizumab in severe allergic asthma

This guideline advises that Omalizumab can be used in the treatment of asthma. It is a monoclonal antibody that binds to IgE and is given every 2 to 4 weeks subcut. We may start seeing patients treated with this, so worth knowing about it. Treatment is to be started and maintained by specialists only. Quite a lot of criteria must be met before use, so it’ll only be used in the most severe asthma, where allergy testing has been positive.

Conduct Disorders in Children

This guideline is about conduct and other antisocial disorders affecting young people. It outlines the kinds of things to cover in the history as well as management strategies. There’s not really anything groundbreaking here, but it’s worth a look if your heart sinks at the mention of ‘behavioural problems’. I’ve gone into more background than I normally do as I wasn’t aware of a lot of this, though it makes sense.
It is also important to be aware of conduct disorders as intervention may help. Up to 50% of children with a conduct disorder go on to have an antisocial personality disorder as adults. It is also associated with poor educational performance, substance misuse and criminal behaviour. There is also a high prevalence of other mental health disorders in affected kids.

The stats are worth noting and just support what you’ll have seen anyway. Prevalence is 5%, though up to 40% in looked after kids and other high risk groups. It is much more common in lower socio-economic groups.

To diagnose a conduct disorder, the child’s behaviour must be:
- Persistent
- Repetitive
- Significantly violating the expected norms of social behaviour for that age.

History and assessment
Consider the following during assessment:
- Using the “Strengths and Difficulties Questionnaire”.  Parents and teachers can fill this out.
- Core conduct disorder symptoms
• Under age 11 – negativistic, hostile or defiant behaviour
• Over age 11 – aggression to people or animals, destruction of property, deceitfulness, theft or severe violations of rules
- Coexisting mental health / neurodevelopmental problems (eg ADHD or autism).
- Learning disabilities
- Substance misuse
- Current functioning, at home, at school and with their peers
- Parenting ability
- Other parental factors (eg mental health problems, substance misuse, domestic violence, other strong adult ties)
- Any safeguarding issues.

Management
- Parent and child training programmes are the mainstay of treatment and we can refer directly to these (via health visitors, school nurses and Sure start Centres). Ensure parents don’t feel blamed and explore concerns that they have about this. From age 9, young people can attend child only groups.
- In some areas identified as having large numbers of at risk children, schools are conducting child programmes.
- CAMHS should be used if there are complicating factors (eg coexisting mental health problem, learning difficulty, substance misuse, ADHD or autism).
- Co-existing ADHD should be treated with medication.
- Risperidone can be used by specialists in severe cases.

Areli Mendoza, Winchester and Southampton Chambers

Dr Areli Mendoza qualified at Mexico City University in 1998. On qualification I did research in Houston and Texas before moving to the UK in 2004. I then worked in paediatrics and neonatal medicine at the Imperial College London and qualified as a GP in 2012 and joined Brune Medical Centre in October. I am married and I have one child.

My special interests include skin diseases, children’s health and sexual health.

I love travelling and baking cakes.

Hyperphosphataemia in CKD

This guideline is really aimed at secondary care as it will be the worst affected patients that suffer with hyperphosphataemia. However, we do have some stable CKD4 patients just under primary care, so it is worth remembering that this can be an issue.

Basically, patients with CKD 4 or 5, should have their phosphate levels checked regularly. They don’t specify how often. The NICE CKD guidance just says to judge how often based upon initial readings and to seek specialist advice if uncertain. Limits vary from area to area, but you are aiming for a level of 0.9 to 1.5 mol/l in dialysed patients.