Minutes of the Exeter Sessional GPs Group
at Darts Farm – 4 June 2013
The meeting was kindly sponsored by:
Colin Leaper
Meda
Laura Roulstone
Boehringer Ingelheim
Cathy Griffiths
Bayer
Attendance:
26 members
Welcome:
Hamish Duncan opened the meeting by thanking the reps for sponsoring. The
financial future of the group meetings as they are currently organised depends on drug
rep sponsorship. At future meetings, in acknowledgement of this fact, the drug reps
will be offered an opportunity to make a short presentation at the beginning of the
meeting. It is also important that members speak to the drug reps prior to the start of
the formal meetings.
Summer social event will be held on Tuesday 6 August at Turf Hotel. Full details
will be posted on website. In order to facilitate booking for the correct number of
people, please e mail Clair or Francesca or, once on the website, use the electronic
system there.
Clinical Commissioning Group – Exeter shutdown afternoon – this is entitled “Early
Diagnosis of Cancer” and organised for 1pm to 6pm on Thursday 11 July. Sessional
GPs including locums are invited and there is a link to the booking form on the
sessional GP website.
New arrangements regarding NHS Pension Scheme – all details are on the sessional
GP website. Anyone requiring an end of year certificate will need to e mail “Shared
Services” as they will not be sent automatically. There is also a form that must be
completed and submitted (legal requirement) along with a cheque for any
underpayment declaring all NHS superannuable income earned during the financial
year and how much superannuation has been paid.
Any questions on cardiology should be submitted via the sessional GP website in
readiness for a future cardiology meeting.
Clinical meeting
Hamish welcomed the speaker Dr Rachel Amherst, Consultant in GU Medicine
Exeter.
GU Medicine Update Dr Rachel Amherst
HIV diagnosis
Definition of late diagnosis is when CD4 < 350 and very late when CD4 < 200.
Increased mortality and morbidity with late diagnosis. Treated HIV patients now
have almost as good life expectancy as those without HIV. However cancer risks are
higher – not just the specific HIV related cancers, but all cancers because
immunocompromise increases propensity to malignancy.
Early diagnosis reduces spread and hence saves money. This is likely to be because
diagnosed patients aware of their condition take less risks as well as treatment
reducing viral load and hence reducing transmission.
In Exeter and rural areas, the prevalence of HIV is relatively low and so there is some
complacency in not looking for it (and so cases that are there are more likely to be
missed).
Ways to increase diagnostic rates in areas of low prevalence:
Screening: all who attend GUM, ante natal patients, blood donors, organ donors.
Testing in line with 2008 HIV testing guidelines which includes many conditions
other than the traditional AIDS-defining conditions e.g. oral thrush, CIN 2 or worse,
lung cancer, dementia, severe psoriasis, severe seborrhoeic dermatitis:
http://www.bhiva.org/documents/Guidelines/Testing/GlinesHIVTest08.pdf
In order to perform the test it is necessary to get informed consent. However pre test
counselling is no longer considered to be required as good practice. “HIV for the
non-specialist” booklet gives full explanation:
http://www.medfash.org.uk/uploads/files/p17am0h8v510dr1f941ebg1sicgpr.pdf
4th generation HIV test includes testing for antigen and for 3 antibodies. Sensitivity at
4 weeks post exposure is 95% but unless risk is deemed to be particularly high then it
is more usual to wait until 12 weeks post exposure. The test costs approx £8 and is
cost effective if one in a thousand are positive.
At the time of sero conversion, patients are highly infectious as viral load is high.
Hence it is worth considering whether to perform HIV test at the time of performing
glandular fever test. Conversely, from the time of exposure to day 14, the patient is
not very infectious.
There is piloting of reporting late HIV diagnosis as a significant event – and looking
at the contributions of practitioner, patient and system failings – with a view to
improving timely diagnosis.
Genital wart treatments
Treatment is for cosmetic reasons – virus remains transmissible post treatment. No
need to treat pregnant women – often the warts resolve post partum. The wart virus
which causes visible genital warts is not the one which causes cervical cancer.
If treated in pregnancy, can only use cryo or TCA.
Podophyllotoxin treatment - Warticon cream is the easiest to use but not currently
available.
- condylline solution is ok for self use in men who can
easily see their warts but too difficult for self use in women – use on area less than
4cm2 bd for 3 days then 4 day break then repeat if needed.
Immunomodulation – imiquimod – use one sachet per application at most. Can cause
ulceration. It is very expensive. Is used 3 times per week – apply in the evening and
wash off in the morning. It does take a while to work.
Genital warts are likely to recur in patients with diabetes. Use of skin preparations
increases risk of recurrence.
Risk factors for genital warts include shaving, thrush, smoking and skin irritation.
Syphilis update
One new case per month on average seen in GUM in Exeter. Mainly in MSM or
women who have had sex with MSM. Often originates from far east or from Russia.
Most are picked up on routine screening but some are sent having been picked up in
other departments – for example unexplained rashes, neurological symptoms and
syphilis testing carried out in the investigation.
Syphilis treatment is reliable and treatment of latent syphilis prevents neurosyphilis.
HVS
Microbiology department is overwhelmed by triple swab tests and these tests need to
be minimised.
In investigation of vaginal discharge in low risk patients pH testing from posterior
fornix is deemed to be sufficient to allow diagnosis – if ph more than 5.5 then treat as
bacterial vaginosis and if pH low then treat as candida. Only treat if symptomatic.
Sexually transmitted infections causing discharge – gonococcus, Chlamydia, herpes,
trichomonas.
Non STI vaginal discharge – candida, bacterial vaginosis, physiological, foreign body,
cervical cancer.
GPs can make referrals direct to GU clinic in Sidwell Street – no need to go through
C+B etc. need to state in letter whether patient will phone to book their appointment
or whether patient expecting an appointment to be sent. GUM has an obligation to
see patient within 48hours of them phoning for the appointment.
Housekeeping
Hamish thanked Dr Amherst for the informative talk and reminded members to sign
the attendance register.
An announcement was also made about a charity auction and dinner on 8th July to
raise money for Blue Ventures to provide sexual and reproductive health care for
people in Madagascar. The event is being organised by Dr Vik Mohan who is a local
sessional GP and medical director for the programme in Madagascar.
Future ESGPG Meetings
2.7.13 Hand orthopaedics. Lt Col Standley. Hand and orthopaedic surgeon
6.8.13 Summer social event Turf Locks
3.9.13 Pensions, CCG update
Meeting time
Please note that the meetings are now scheduled to start at 7pm with the guest speaker
planned to commence at 7.30pm.
Committee Contacts
Dr Hamish Duncan (chairman)
Dr Diane Baker (appraisal support co-ordinator)
Dr Nimita Gandhi (educational co-ordinator)
hamishduncan@hotmail.com
dianebaker625@hotmail.com
nimitagandhi@nhs.net
Dr Sarah Hemingway (funding co-ordinator)
Dr Megan James (treasurer)
Dr Kathryn Shore (minutes secretary)
Dr Clair Homeyard (social secretary)
Dr Francesca Vasquez (social secretary)
Dr Megan James (LMC link)
sarahhemingway@doctors.org.uk
meganbyles1@gmail.com
kathrynshore@btinternet.com
clair_homeyard@hotmail.com
cesca1@hotmail.com
meganbyles1@gmail.com