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1. Painful rectal bleeding is often a fissure. This is a common reason to refer to secondary care. To find the fissure can be tricky. Use a bright light and part the buttocks to carefully inspect the anus. Useful treatments include rectogesic or diltiazem topically. This needs to be applied just inside the anus; it is not that useful externally.
2. A correctly treated fissure would normally heal within 6 weeks. It is worth telling the patient this. If they persist after 6 weeks, the surgeons would be keen to review the patient to exclude anal cancer or dermatological conditions that can cause fissuring.
3. A new pathway and form (form attached) have been developed to reflect the changes in NICE guidance for 2 week rule cancer referrals. These will be used from July onwards. Please familiarise yourself with the new form. There are some changes which will result in a lower threshold for 2 week referrals.
2 week cancer referral forms
Cancer - Macmillan Cancer Support Rapid Referral Guidelines
Following a recent meeting with Dr Jane Fletcher it was suggested to put together suggestions for local management of lung cancer, to improve our management between primary and secondary care. We have revised our management of lung cancer patients in the last 6 months so initially it may help to explain changes and how this may alter the way we suggest patients are managed pre‐ referral. The pathway is also in
The pathway is also in appendix.
Following receipt of a 2WW referral with suggested lung cancer (either on basis of abnormal CXR/CT, symptoms as per NICE and/or high clinical suspicion) all referrals are reviewed on a daily basis by consultant. If required a CT scan is organised at this point, which is done in the next 1‐4 days. We have introduced a consultant led virtual review clinic at day 5‐7 post referral. The referring information, images and
We have introduced a consultant led virtual review clinic at day 5‐7 post referral. The referring information, images and current patient record is reviewed and management plan is decided prior to the first clinic appointment. If required further imaging (eg PET scan) and/or detailed lung function (if possibility of surgery/radical treatment) is requested for the next week, prior to OPD appointment. The best method of invasive investigation/biopsy is identified and pre‐booked, if possible on the day of outpatient clinic. Clinic appointment is in the next week (by latest 14 days post referral from primary care). If any tests are pre‐arranged the patient is contacted by our lung cancer specialist nurses prior to first appointment (patient phoned within one week from primary care referral) to explain what has been arranged and answer queries. The patient is also given contact details at this point. We are currently completing a patient satisfaction questionnaire but ad hoc feedback on this process of early phone contact (
If any tests are pre‐arranged the patient is contacted by our lung cancer specialist nurses prior to first appointment (patient phoned within one week from primary care referral) to explain what has been arranged and answer queries. The patient is also given contact details at this point. We are currently completing a patient satisfaction questionnaire but ad hoc feedback on this process of early phone contact (pre clinic review, after CT scan) has thus far been very positive. We have introduced this pathway in the last 6 months and have had very positive results from post introduction audit, showing;
- quicker investigation times ( we have met all national targets for the last 6 months) less invasive tests and
- less invasive tests and less procedure cancellations
- less visits to outpatient appointments for patients. We are currently looking at further refining the pathway to streamline care between primary and secondary care (and would welcome any feedback), including the possibility of a straight to CT scan for flagged, abnormal CXR’s. In
We are currently looking at further refining the pathway to streamline care between primary and secondary care (and would welcome any feedback), including the possibility of a straight to CT scan for flagged, abnormal CXR’s.
In discussions, there were a number of points that were raised.
Who/when to refer?
This is summarised by NICE guidance (see appendix) Acutely unwell‐ immediate hospital referral CXR should always be arranged in primary care. Management can be guided from this‐ CXR flagged/suggests CT for possible lung cancer or ongoing unexplained haemoptysis‐ Please refer with this under 2WW. We will organise CT scan CXR normal‐ if ongoing concern either (depending on trigger symptom/signs)
- Refer under 2WW depending on degree of clinical concern/symptoms (as per NICE)
- Arrange urgent CT scan in community which will be done and reported in 4/52
If organising CT scan for lung cancer this should be requested as CT chest/abdomen with contrast (not high resolution CT chest/HRCT). We would ask that flagged CXR’s suspicious for cancer are at present referred under 2WW and not investigated in primary care as this leads to delays in probable cancer diagnoses.
We would ask that faxed 2WW referrals are sent ASAP if phoning to arrange referral. It is only with faxed info that we can start our pathway and decide on suitable investigations. We have occasionally found delays of up‐to a week for the fax to come through. We would ask that a list of medications is sent with the 2WW referral . We need to know this to be able to pre‐arrange invasive test (especially anticoagulation/insulin etc).
Anything else that can be done on referral to help?
We would ask if possible that blood tests are requested on referral. For CT contrast up‐to date renal function is required, and leads to delay if none available. If testing this we would ask that all blood tests are completed at the same time (to save repeated sampling for patients)‐ FBC U/E LFT Calcium INR/coag
High emergency presentations in Wirral
We have high emergency presentations of lung cancer locally (40‐45% of diagnoses) due to many factors. Such presentation has worse prognosis and generally points to more advanced disease. Early recognition/diagnosis is key for potential curative treatment which would be our aim. We would recommend a low threshold for CXR referral for those with chest symptoms (especially in high risk groups‐ smokers, asbestos exposure, family history etc), as per new 2015 NICE guidance attached. On recent local audit of 3 months 2WW cancer referrals only 3/36 had normal CXR’s so this should always remain first investigation of choice.
Who to contact if concerned?
For patients currently being investigated/known to the lung cancer services the best contacts are the lung cancer specialist nurses‐ Kay Hughes or Anita Gillen, or the named consultant for their care via their secretary.
The lung cancer specialist nurses can be contacted on 604 7482
For advice pre‐referral please contact Dr Andrew Wight via secretary on 604 7768
- Beware palpitations, presyncope or syncope associated with exercise or just after exercise – higher chance of significant abnormality
- Palpitations at extremes of adult life more likely to have significant cardiac cause or effect
- 24 hr. tapes good for looking at rate control in people with known AF but not very sensitive in detecting paroxysmal AF [7 day event recorder better]
- Bradycardia in the absence of symptoms or evidence of 2nd degree block is not an indication for pacing.
- First degree AV block is not an indication for pacing and nor is high 2nd degree AV block – also known as mobitz type 1 [wekenbach] which is common in young athletic people especially at night
- Elderly patients with high 2nd degree AV block as above should have regular review to ensure not progressing to more serious disease ie 2 to 1 block or mobitz type 2 or complete heart block all of which require PPM
- Pauses greater than 2 seconds during day or 3 seconds at night on 24 hr. tape even in absence of symptoms would be considered for PPM especially in elderly
- Patients with high degree of atrial ectopic load [10%] on 24hr tape are high risk for developing or having paroxysmal AF permanent AF
- Patients with high degree of ventricular ectopic load should be considered for further assessment to exclude cardiomyopathy or ischaemia as cause
- Ectopic beats that disappear on exercise e.g. with Exercise testing and structurally normal heart have good prognosis
- Stronger indications needed for PPM in younger patients  as more likely to need multiple box changes with increasing expectancy
- In patients with known symptomatic bradycardia but no evidence of pauses or AV block consider supervised ETT or 24 hr. tape to establish if they demonstrate an intrinsic chronotropic response in which case PPM not indicated
- Commonest indication for PPM is for elderly patients with symptomatic Sino atrial disease
- PPM also indicated in patients with symptomatic AF at low rates even if this is caused by rate-limiting drugs needed to control episodes of fast ventricular response
- Clinical correlation between symptoms and heart rhythm and rate in patients with funny dos is key before PPM
- REVEAL devices now available that can regularly record heart activity for up to several months in patients with infrequent or atypical episodes
The Wirral Dermatology department now have a section of the website for further tips on managing skin conditions. The section is called skin deep.
Dermatology scenario – commonly missed condition. Erythematous patch on back noticed by
Erythematous patch on back noticed by spouse. Asymptomatic and patient unaware of it. Mentioned when attended for something else. O/A 1 cm red flat patch. No scaling. Not bothering patient and told to told to observe 2 years later represents patch now starting to crust. O/A 1.5 cm crusted patch with slightly raised edge. Slightly itchy. Given Daktacort as ?‘tinea’ and then over the subsequent few months topical steroids as ?eczema and then dovobet as ?psoriasis. Presents again further year later with 2.5 cm erythematous patch. Note slightly raised pearly edge in some areas ‘string sign’.
Treatment difficult as some areas now indurated and no longer ‘superficial’ such that Aldara, PDT, etc might not work, cryotherapy will cause significant morbidity and surgery will mean large scar.
Learning Point Persistent patch consider BCC and check for shiny erythematous telangiectatic surface or ‘pearly edge.