Issue 21.
Urgent referrals for people with breast
lumps
A recent edition of ‘Guidelines in
practice’ contained useful advice on referring patients with breast lumps.
If you suspect that your patient has breast cancer
you should make an urgent referral. GPs are encouraged to do this using same-day direct
booking systems such as electronic media, telephone or fax. It is important that you
should only use the classification "urgent" for those patients whose symptoms
are highly suggestive of breast cancer. The main features of this group will be:
A discrete lump in the appropriate age group
Definite signs of cancer such as:
ulceration
skin nodule
skin distortion
Other presentations of breast cancer are much less
common, e.g. nipple discharge or pain in the absence of a lump.
Conditions that require referral to a
surgeon with a special interest in breast disease.
Lump
Any new discrete lump
New lump in pre-existing nodularity
Asymmetrical nodularity that persists at review
after menstruation
Abscess
Cyst persistently refilling or recurrent
cyst
Pain
If associated with a lump
Intractable pain not responding to reassurance,
simple measures such as wearing a well-supporting bra, and common drugs
Unilateral persistent pain in
post-menopausal women
Nipple discharge
Women under 50 with:
bilateral discharge sufficient to stain clothes
blood-stained discharge
persistent single duct discharge
All women aged 50 and over
Nipple retraction or distortion, nipple eczema
Change in skin contour
Family history
Request for assessment by a woman with a strong
family history of breast cancer.
Lump
Any new discrete lump
New lump in pre-existing nodularity
Asymmetrical nodularity that persists at review
after menstruation
Back to top
Technology assessment, systematic
reviews and meta-analyses
Meta-analysis is a statistical methodology for
combining data from similar studies that address a single narrow question, typically
efficacy of a treatment. There are actually two types of meta-analysis.
One type typically limits itself to RCTs and attempts to reach a
conclusion that implies or openly claims to be a demonstration of causality. This requires
very narrow inclusion criteria designed to achieve rigorous demonstrable homogeneity. But
it is also sometimes useful to carry out a descriptive meta-analysis. This is designed to
simply find out what the consensus is for a group of studies, which may be very
heterogeneous. If the studies strongly point in a particular direction in spite of the
heterogeneity, that can be interesting, although it may not indicate a cause and effect.
If the studies point in different directions, analysis of the sources of the differences
can be informative. Both meta-analyses have different purposes.
Systematic reviews are broader than either of the
above. They may have strict inclusion requirements designed to prevent picking only the
positive studies but if insufficient similar controlled trials are available,
heterogeneous and even uncontrolled data may be analysed.
Technology assessment is not limited to
effectiveness, but may address many questions, including different treatment strategies,
different patient groups, different diagnostic strategies leading into treatment
strategies, patterns of care, and regulatory, economic and ethical issues. While
clinicians are sometimes genuinely interested in a single narrow question, for which
meta-analysis or systematic review is suitable, healthcare consumers and policy makers
almost always are mainly
interested in the full technology assessment approach.
Back to top
Treatment of MRSA
Guidelines from the July Drugs and Therapeutics Journal
Infected skin lesions
Cover infected or colonised lesions (e.g. wounds, pressure sores) with
an antiseptic (e.g. chlorhexidine, povidone-iodine) dressing.
Small lesions – apply mupirocin (2.0%) in polyethylene glycol base
up to three times daily for no more than 7-10 days. Avoid prolonged or repeated
courses, which encourage selection of mupirocin resistance in Staphylococcus aureus.
Raw areas or burns – consider mupirocin in a paraffin base (plus
systemic therapy as indicated).
Avoid
mupirocin in polyethylene glycol: systemic absorption of the
vehicle risks nephrotoxicity.
Accompanying measures to eradicate carriage (e.g. in the nose or on the
skin or perineum) (see Table 2).
Systemic infections
Obtain appropriate samples for culture and antibiotic sensitivity
testing.
Treatment of severe infections is urgent; first-line antibiotic therapy
should be with a glycopeptide administered intravenously.
EITHER Vancomycin by i.v. infusion*
Adults: 500 mg over at least 60 minutes every 6 hours or 8g over at
least 100 minutes every 12 hours.
Neonate: 15 mg/kg initially, then 10 mg/kg every 8-12 hours.
Child (over 1 month): 10 mg/kg every 6 hours.
* monitor plasma concentrations: maximum peak (2 hours post infusion)
concentration 30 mg/L; maximum trough (pre-dose) concentration 20 mg/L.
OR Teicoplanin by i.v. infusion or injection†
Adults: 400 mg initially, then 200 mg daily (severe infections 400 mg
every 12 hours for three doses, then 400 mg daily).
Neonate: initially single dose 16 mg/kg by i.v. infusion, then 8 mg/kg
daily by i.v. infusion.
Child (over 2 months): initially 10 mg/kg every 12 hours for three
doses by i.v. injection or infusion, then 6 mg/kg daily.
† maintain trough concentration above 10mg/L.
In patients who are not severely ill, oral therapy may be suitable,
depending upon the susceptibility of the organism e.g. rifampicin (0.6-1.2g daily in two
to four divided doses) PLUS sodium fusidate (usual adult dose 500 mg every 8 hours).
Ciprofloxacin or a macrolide or trimethoprim are other alternatives
Back to top
|
