Primary Care Guidelines

The video version of this podcast can be found here:

·      https://youtu.be/TQB5tJvM0VM

This video refers to guidelines produced by a number of organisations (details below). Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by any of them.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I cover what to do if thrombocytopenia is found, always focusing on what is relevant in Primary Care only. The information is based on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

My summary of the guidance consulted can be found here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mQ4ZjYGRH1wkGBdc?e=Zuxx84

The resources consulted can be found here:

·      Camden CCG guidance: 1456246258-2f3891e610beaa6533f2c0ad7866e776.pdf(Review) - Adobe cloud storage

·      Manchester Adult anaemia guide: https://acrobat.adobe.com/id/urn:aaid:sc:EU:f96fe528-0a47-457c-b29a-a7efb87221e0

·      Manchester Haematology GP guide: https://mft.nhs.uk/app/uploads/2021/02/MFT-Haematology-GP-Pathway-Guide-v4-11.2.21.pdf

·      King’s Health Partners: https://www.kingshealthpartners.org/assets/000/002/294/KCH_-_king_s_health_partners_-_quick_guide_to_haematology_original.pdf

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to cover what to do when we encounter thrombocytopenia on a full blood count, always focusing on what is relevant in Primary Care only.

I have based this episode on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners. The links to them are in the episode description.

Right, let’s jump into it.

Thrombocytopenia is the platelet count is low, which is defined as a platelet count below 150 × 10⁹ per litre.

But before we assume a true low platelet count, we need to remember that thrombocytopenia can often be an artefact. This happens when platelets clump together in the EDTA sample tube, giving a falsely low automated count.

So, the first step is always to confirm the result with a repeat full blood count and a blood film. The blood film not only rules out platelet clumping but can also provide important clues about the underlying cause.

There are many potential causes of thrombocytopenia so, let’s have a look at them:

First, we have alcohol excess. Chronic alcohol use can directly suppress bone marrow production and shorten platelet lifespan. It is also frequently associated with chronic liver disease, where the spleen often becomes enlarged due to portal hypertension destroying more platelets than usual — a process known as hypersplenism.

Then we have recreational drugs, which can also impair platelet production or trigger immune-mediated destruction.

Then, travel history is also very important. Malaria, for example, often presents with thrombocytopenia, sometimes even before fever or parasitaemia becomes obvious.

Tuberculosis can also cause thrombocytopenia, either through bone marrow involvement or immune-mediated mechanisms.

Then we should consider liver and renal disease.

In chronic liver disease we have already explained that hypersplenism is the most common cause of thrombocytopenia in liver disease.

In renal disease, platelet lifespan is reduced because uraemia makes platelets more fragile, causing them to break down more quickly. In addition, bone marrow suppression may also occur.

Then we have medications as another common culprit.

NSAIDs, heparin, digoxin, quinine, anti-epileptics, antipsychotics and proton pump inhibitors are all recognised causes. Most drug-induced thrombocytopenia is caused by either:

• immune-mediated platelet destruction, or

• direct suppression of platelet production in the bone marrow.

Heparin is the main exception because it causes thrombocytopenia through a unique immune reaction that activates platelets, leading to their consumption and a fall in the platelet count.

Another possible cause are nutritional deficiencies, especially vitamin B12 and folate deficiency, which can impair bone marrow production and lead to thrombocytopenia, often alongside other cytopenias.

We also need to consider viral causes. For example, Epstein–Barr virus frequently causes a temporary drop in platelets, which typically resolves within a few weeks.

HIV and hepatitis B or C can cause persistent thrombocytopenia either through direct bone marrow suppression, immune-mediated destruction, or associated splenomegaly.

Then, malignancy is also on the list, because both haematological cancers and solid tumours can infiltrate or suppress the bone marrow.

Then we have bone marrow failure syndromes, such as aplastic anaemia, which will often present with thrombocytopenia together with anaemia and neutropenia.

Another cause is immune thrombocytopenic purpura, or ITP, which is an autoimmune condition that destroys platelets. In adults, ITP can be acute or chronic, and the platelet count can fall to very low levels even when the patient looks otherwise well.

Finally, autoimmune conditions such as SLE can present with thrombocytopenia as part of a broader immunological process.

Now that we have had a look at the causes, how should we manage these patients?

We have already mentioned that we should confirm thrombocytopenia with a repeat FBC and blood film. If the thrombocytopenia is confirmed, we will need to check if there are urgent criteria.

First of all, we should arrange urgent same-day hospital assessment when the platelet count is below 20 × 10⁹ per litre and any concerning clinical features are present. These include:

• Active bleeding, even if minor, because bleeding risk rises sharply at very low platelet levels.

• An abnormal blood film, such as the presence of blasts suggesting acute leukaemia, or red cell fragments suggesting microangiopathic haemolysis, as these findings indicate potentially life-threatening conditions.

• And finally an altered consciousness or confusion, which may point to serious systemic illness, intracranial bleeding, severe infection, or thrombotic microangiopathy.

We should make an urgent outpatient haematology referral if the platelet count is below 50 × 10⁹ per litre, even without symptoms. This is because at this level, the risk of spontaneous bleeding increases, and many underlying causes — such as ITP, bone marrow failure, or haematological malignancy — require urgent assessment.

Additionally, when the platelet count is below 50, it is unsafe to continue antiplatelet agents or anticoagulants, so these should be stopped unless a specialist advises otherwise.

We should also make an urgent outpatient haematology referral when the platelet count is between 50 and 100 and certain concerning features are present. These include splenomegaly, lymphadenopathy, other cytopenias, pregnancy, or planned surgery. This is because all of these situations increase the risk of serious underlying disease or increase the risk of bleeding.

However, if the platelet count is above 50 and none of the urgent referral criteria are present, we should then arrange the following baseline investigations:

Firstly, we begin with a repeat full blood count and a blood film to confirm the thrombocytopenia, rules out platelet clumping, and look for abnormal cell morphology.

Then we will check Vitamin B12 and folate levels to rule out deficiency.

Ferritin and iron studies are also helpful, given that iron deficiency can occasionally contribute to low platelets.

Inflammatory markers, such as ESR and CRP, which can suggest infection, inflammation, or an underlying autoimmune process.

An autoimmune profile to exclude autoimmune-mediated platelet destruction.

Renal, liver and thyroid function tests to identify chronic liver disease, renal failure and thyroid disease given that both hypo- and hyperthyroidism — can contribute to thrombocytopenia.

Then, viral serology for HIV, hepatitis B and hepatitis C as these viruses can be associated thrombocytopenia.

And finally, we should perform any other investigations suggested by the history or examination, for example, malaria testing after relevant travel, a TB workup, coagulation studies if there is bleeding, etc.

After the initial baseline investigations, if no obvious cause is found, the platelet count is above 50 and none of the urgent referral criteria are present, we can repeat the full blood count after 4 to 6 weeks.

If thrombocytopenia persists and remains unexplained, we should then refer the patient routinely to haematology.

So that is it, a review of the assessment and management of thrombocytopenia.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/lhtciu3O8tc

The video on raised bilirubin pattern can be found here:

·      https://youtu.be/ndAus37PfsE

The video on hepatitic pattern abnormal LFTs can be found here:

·      https://youtu.be/rIX46swVSfg

This episode refers to guidelines on the management of abnormal liver function tests by the British Society of Gastroenterology. Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by them.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I cover what to do when we encounter abnormal LFTs with a cholestatic pattern, always focusing on what is relevant in Primary Care only. 

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

My summary guide can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mQ8MRxaNYnA1_pzh?e=H2U7rS

The resources consulted can be found here:

BSG- British Society of Gastroenterology:

·      bsg.org.uk/clinical-resource/guidelines-on-abnormal-liver-blood-tests

·      Guidelines on the management of abnormal liver blood tests (bsg.org.uk)

o  First published on:

o  BMJ article:

o  Guidelines on the management of abnormal liver blood tests | Gut (bmj.com)

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to cover what to do when we encounter abnormal LFTs with a cholestatic pattern, always focusing on what is relevant in Primary Care only.

This episode is based on the British Society of Gastroenterology guidelines on abnormal Liver function tests. A link to it is in the episode description.

Right, let’s jump into it.

And let’s start by remembering that there are three common patterns of abnormal liver function tests or LFTs:

1. A cholestatic pattern, normally showing a high ALP and GGT, which is what we will concentrate on today.
2.  An isolated raised bilirubin with otherwise normal liver tests.
3. And a hepatitic pattern, with a raised ALT and AST indicating hepatocellular injury. By the way, if you are interested in finding out more about the last two types, make sure to watch the corresponding episodes on this channel. The links are in the episode description.

As we have said, LFTs showing a cholestatic pattern normally present with a high ALP and GGT.

Alkaline phosphatase, or ALP, is produced mainly in the liver but is also found in bone, intestines, kidneys and the placenta. Levels are physiologically higher in childhood because of rapid bone growth, and in pregnancy due to placental production. Raised ALP can come from either hepatic or non-hepatic sources.

The main source of non-hepatic ALP is bone. ALP increases in bone disease because it is produced by osteoblasts, the cells responsible for forming new bone. Any condition that increases osteoblast activity or bone turnover—such as healing fractures, Paget’s disease, bone metastases, or vitamin D deficiency—causes osteoblasts to increase their activity, releasing more ALP into the circulation.

We should remember that the most common cause of an asymptomatic, non-hepatic raised ALP is vitamin D deficiency. And let’s remember that vitamin D deficiency increases bone turnover because low vitamin D reduces calcium absorption from the gut. To maintain normal calcium levels, parathyroid hormone rises and stimulates bone breakdown to release calcium. This increase in bone remodelling activates osteoblasts leading to a rise in ALP.

But as we are focusing on liver function tests, what is the source of a raised hepatic ALP? From a pathophysiological perspective, hepatic ALP rises when bile flow is impaired, also known as cholestasis. And, why does cholestasis cause a rise in ALP? It happens because alkaline phosphatase is found in high concentration in the cells lining the bile ducts. When bile flow is impaired, pressure builds up in the biliary system and the bile duct epithelium becomes irritated. This stimulates these cells to produce and release more ALP into the bloodstream. This is the reason why ALP rises in, for example, gallstone disease, strictures, or cholangitis.

On the other hand, γ-glutamyltransferase, or GGT, is found in the liver but not in bone. Therefore, when ALP is raised, measuring GGT helps determine whether the source is hepatic or non-hepatic. A raised ALP with a normal GGT suggests a bone-related cause, whereas a raised ALP with a raised GGT supports a hepatic origin and should prompt further assessment of cholestatic liver disease.

GGT rises in cholestasis because it is also highly concentrated in the cells lining the bile ducts. When pressure builds up in the biliary system, these cells release more GGT into the bloodstream. In addition, cholestasis causes oxidative stress because retained bile acids are toxic to liver cells. In response, the liver increases GGT production, as GGT is involved in antioxidant and detoxification pathways, leading to the characteristic rise in cholestatic liver disease.

A high GGT can also be due to obesity, excess alcohol, or medications. In obesity and NAFLD, fat accumulation within the liver creates oxidative stress, so the liver up-regulates GGT to protect hepatocytes from free radical damage. In this context, an elevated GGT reflects metabolic stress rather than structural cholestasis. In alcohol use, ethanol metabolism produces toxic intermediates that also generate oxidative stress, which further stimulates GGT production as part of the liver’s detoxification response.

We will not go into detail on how to proceed with an isolated raised ALP, that is, with a normal GGT, as today we are focusing on cases where there is clear hepatic involvement, meaning that both ALP and GGT are high in a true cholestatic pattern.

How should we investigate and manage these patients?

When we manage patients with any abnormal liver function tests, we must begin by recognising red flags that require urgent action. According to the British Society of Gastroenterology guidelines, if there are signs of synthetic liver failure – such as unexplained clinical jaundice, a low albumin, or a raised INR – or if there is a suspicion of malignancy, for example unexplained weight loss or marked cholestasis, then the patient should be urgently referred or admitted for specialist assessment.

If the pattern is cholestatic, we will proceed with a full liver screen. This is because cholestatic abnormalities are often related to structural biliary disease, autoimmune cholestatic conditions, or infiltrative disorders, and these require a broader diagnostic approach than simple repeat testing.

What tests should be done in a full liver screen?

A full liver screen should include an ultrasound scan of the liver and biliary tree, which is the first-line imaging test. Ultrasound helps identify biliary dilatation, gallstones, strictures, masses, or features of chronic liver disease. In addition to imaging, blood tests should include hepatitis B and C screening, an autoantibody screen, serum immunoglobulins, ferritin and transferrin saturation, and, often and where clinically appropriate, a coeliac screen, alpha-1 antitrypsin levels, and caeruloplasmin. These tests collectively help detect autoimmune cholestatic diseases such as primary biliary cholangitis, metabolic conditions such as haemochromatosis or Wilson’s disease, and chronic viral hepatitis.

It is also worth emphasising that this full liver screen is recommended not only for cholestatic abnormalities but also for patients who present with a hepatitic pattern, as the BSG guideline advises a comprehensive assessment irrespective of the pattern or the degree of derangement once initial red flags have been excluded.

The management in primary care is fairly simple, because the British Society of Gastroenterology recommends that once initial investigations have been completed, these patients should be referred to secondary care for further assessment. This applies both when a cholestatic picture come with abnormalities in the liver screen and also if the ALP and GGT remain persistently high even in the context of normal investigations.

Referral is indicated because persistent cholestatic abnormalities indicate underlying pathology that usually cannot be adequately diagnosed or managed in primary care and requires specialist input.

So that is it, a review of abnormal LFTs with a cholestatic pattern.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/3QL2R2IV83o

This video refers to guidelines produced by a number of organisations (details below). Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by any of them.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I cover what to do if thrombocytosis is found, always focusing on what is relevant in Primary Care only. The information is based on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

My summary of the guidance consulted can be found here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mQ4ZjYGRH1wkGBdc?e=Zuxx84

The resources consulted can be found here:

·      Camden CCG guidance: 1456246258-2f3891e610beaa6533f2c0ad7866e776.pdf(Review) - Adobe cloud storage

·      Manchester Adult anaemia guide: https://acrobat.adobe.com/id/urn:aaid:sc:EU:f96fe528-0a47-457c-b29a-a7efb87221e0

·      Manchester Haematology GP guide: https://mft.nhs.uk/app/uploads/2021/02/MFT-Haematology-GP-Pathway-Guide-v4-11.2.21.pdf

·      King’s Health Partners: https://www.kingshealthpartners.org/assets/000/002/294/KCH_-_king_s_health_partners_-_quick_guide_to_haematology_original.pdf

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to cover what to do when we encounter thrombocytosis on a full blood count, always focusing on what is relevant in Primary Care only.

I have based this episode on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners. The links to them are in the episode description.

Right, let’s jump into it.

Thrombocytosis is when the number of platelets is high, which is usually defined as a raised platelet count above 450 × 10⁹/L.

But before moving on, let’s clarify the terminology: should we call it thrombocytosis or thrombocythemia? There is an important difference. Thrombocytosis is much more common and arises as a secondary response to another condition, which is why it is also known as reactive thrombocytosis. In contrast, thrombocythemia, also called primary or essential thrombocythemia, is far less common and represents a myeloproliferative disorder in which the bone marrow produces platelets in an uncontrolled, abnormal way.

Another important distinction is that patients with reactive thrombocytosis have normal platelets, so their risk of thrombosis and bleeding is relatively low. On the other hand, patients with thrombocythemia have abnormal platelets, which increases their risk of both blood clots and bleeding complications. From a clinical perspective, thrombocythemia often presents with splenomegaly and a platelet count greater than 1000 × 10⁹/L.

So, let’s have a look at the possible causes. Causes of thrombocytosis include:

• Iron Deficiency Anaemia: which is one of the most common causes of reactive thrombocytosis. When iron levels are low, the bone marrow increases its overall activity in an attempt to compensate for the anaemia. Although iron deficiency limits the production of red blood cells, platelet production is not restricted in the same way. As a result, the bone marrow produces more platelets. In addition, inflammatory signals associated with chronic iron deficiency can further stimulate thrombopoietin pathways, increasing platelet numbers even more. This is why thrombocytosis often resolves once the iron deficiency is corrected.

• Another cause is Malignancy, because some tumours release inflammatory cytokines that eventually increase platelet formation. This reactive response is common in several solid cancers, particularly the “LEGO” cancers, that is:

• Lung

• Endometrium

• Gastric

• and Oesophageal cancer

• Another cause is general Inflammation, where cytokines stimulate excessive platelet production.

• Also Infection, which can cause transient reactive thrombocytosis.

• Post-splenectomy and hyposplenism, such as in coeliac disease, since the spleen normally helps remove circulating platelets.

• Post-operative states, where inflammation and stress responses increase platelet counts.

• And finally, a primary myeloproliferative disorder, such as essential thrombocythemia.

How should we respond to thrombocytosis?

The criteria for urgent haematology referral are:

• A platelet count exceeding 1000 × 10⁹/L, which raises concern for a myeloproliferative disorder and a significant risk of thrombosis.

• Splenomegaly, which may indicate a primary haematological process such as essential thrombocythemia or myelofibrosis.

• A recent history of thromboembolism, as thrombocytosis can contribute to recurrent clotting events.

• A platelet count above 600 × 10⁹/L in a patient at high risk of thromboembolism or cardiovascular disease, since the combination significantly increases clinical risk.

• Neurological symptoms, which may reflect microvascular complications associated with very high platelet counts.

• Any signs of malignancy, given that multiple cancers can cause reactive thrombocytosis.

• any other significant abnormal full blood count indices, which may suggest a bone marrow disorder rather than a reactive process.

• And finally, if there is Abnormal bleeding. And let’s stop here for a moment and discuss how it is possible that thrombocytosis can be associated to a high risk of both thrombosis and bleeding.

On one hand, thrombosis risk in thrombocytosis is due to the high number of circulating platelets, which makes clots more likely. In addition, inflammation causing reactive thrombocytosis can also create a prothrombotic environment. Together, these factors increase the thrombosis risk.

On the other hand, bleeding risk in thrombocytosis can occur for two main reasons. First, in primary or essential thrombocythemia, the platelets produced by the bone marrow are structurally and functionally abnormal and these abnormal platelets do not work effectively, so clot formation is impaired. Secondly, thrombocytosis may affect the von Willebrand factor. Von Willebrand factor is a protein that helps platelets stick to damaged blood vessels and to each other, making it essential for the first steps of clot formation. However, when platelet counts become very high, the excess platelets bind and remove the most active forms of von Willebrand factor from the circulation. This leads to a functional depletion known as acquired von Willebrand syndrome. It explains the paradoxical situation in which a patient can have thrombocytosis and yet be at increased risk of bleeding.

If none of the urgent referral criteria are present, we will investigate for underlying causes by arranging the following initial tests:

• A repeat full blood count, to confirm that the thrombocytosis is persistent.

• A blood film, which may reveal abnormal platelet morphology or other features suggestive of a myeloproliferative process.

• Inflammatory markers such as ESR and CRP, since inflammation is a common cause of reactive thrombocytosis.

• Ferritin and iron studies, as iron deficiency frequently elevates platelet counts.

• And we will consider a coeliac screen, because coeliac disease can lead to hyposplenism or iron deficiency, both of which are associated with thrombocytosis.

If the patient is asymptomatic and no obvious cause is identified, we will repeat the full blood count 4 to 6 weeks later. If the thrombocytosis persists above 450 × 10⁹/L, we will refer to haematology routinely for further assessment.

So that is it, a review of the assessment and management of thrombocytosis.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/p6YSowcUuEo

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in December 2025 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The Full NICE News bulletin for December 2025 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2025-12-01&to=2025-12-31&ndt=Guidance&ndt=Quality+standard

The updated guideline on Child maltreatment: when to suspect maltreatment in under 18s [CG89] can be found here:

·      https://www.nice.org.uk/guidance/ng253

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in December 2025, focusing on what is relevant in Primary Care only.

And this time we have just one updated guideline that is relevant to us in General Practice: the guideline on when to suspect maltreatment in children.

Right, let’s jump into it.

In December 2025, NICE updated the guideline Child maltreatment: when to suspect maltreatment in under 18s. The core change in this update is the addition of a definition of the term “independently mobile.”

Before this update, the NICE guideline used the term “independently mobile” in several key recommendations, but did not define what that term meant. We were expected to interpret it based on our own judgement. This led to variation in practice, particularly when assessing injuries such as bruises, lacerations, and abrasions. Different clinicians could reasonably reach different conclusions about whether a child met this threshold, even when looking at the same clinical picture.

The term was sometimes difficult to interpret as to whether it meant rolling, crawling, bottom-shuffling, cruising, or walking, given that there was no shared or agreed definition in the guideline.

The definition has been developed using a formal consensus process and “independently mobile” is now clearly defined as a child who can move around independently without support, rather than relying on being placed or carried.

Therefore, a child should be considered independently mobile if they can do any of the following:

• crawl
• bottom shuffle
• pull themself up into a standing position using an object, for example, furniture
• move into a standing position unaided
• cruise (that is, move from place to place holding onto an object, for example, furniture)
• climb, for example onto furniture or stairs
• walk using a push-along walker
• or walk unaided.

Children under 12 weeks typically lack the muscle strength, coordination and neurological maturity needed for independent mobility. However, age alone should not be used to determine whether a child is independently mobile. 

This definition has now been added in three areas, specifically in recommendations on:

• bruising and petechiae,

• lacerations, abrasions and scars,

• and burn or scald injuries.

Compared with the previous version, the key difference is clarity, not threshold. The level of concern for injuries has not been raised or lowered. Instead, we now have a shared understanding of which children fall into the higher-risk group when assessing unexplained or concerning injuries.

Otherwise no other major changes were made to recommendations on child abuse and neglect.

Right, this is the end of the update itself.

And, as we have a brief episode today, let’s now look at a brief summary of this guideline. And the first thing to say is that the aim of the guideline is to help us recognise features that should raise concern and prompt further safeguarding action. We are not expected to confirm abuse, but to recognise the risks and act appropriately.

Let’s now briefly review some examples of when to suspect or consider maltreatment. These are situations that may need urgent safeguarding action or discussion with local safeguarding leads.

We should suspect maltreatment when there are injuries with no explanation, or an explanation that does not fit, especially:

– bruising, cuts, abrasions, burns or scalds in a child who is not independently mobile,

– bruises with clear shapes, such as hands, grips, or ligatures,

– burns or scalds with clear patterns or signs of forced immersion,

– multiple injuries or injuries of different ages,

– injuries that are symmetrical or in unusual locations,

– and injuries that are in areas normally covered by clothing.

We should also suspect maltreatment with serious injuries without adequate trauma, including:

– fractures, especially multiple fractures or rib fractures in infants,

– fractures of different ages,

– intracranial injury without a major accidental cause,

– retinal haemorrhages or unexplained eye injuries,

– and spinal, abdominal, or chest injuries that are unexplained, even if there are no external signs.

Additionally, we should suspect sexual abuse when there are clear indicators, including:

– genital, anal, or perianal injury without an accidental explanation,

– and pregnancy in a child under 13 years, which is a strong indicator of maltreatment.

Pregnancy in 13- to 15-year-olds should prompt assessment for sexual abuse.

We should suspect neglect when there are strong indicators, such as:

– repeated failure to provide basic care, food, warmth, or safety,

– and failure to seek medical help that puts the child at risk.

We should also consider possible neglect, if there is, for example:

– poor hygiene or inappropriate clothing,

– an unsafe home environment,

– missed immunisations or health reviews,

– and severe or ongoing infestations,

And we should be concerned if parents or carers:

– fail to give essential medication,

– repeatedly miss important appointments,

– or do not seek medical help when appropriate.

Also, Poor school attendance without a clear reason and repeated or unusual healthcare attendances, especially across multiple services, should also raise concern.

Additionally, we should consider fabricated or induced illness when:

– reported symptoms do not match clinical findings,

– and when symptoms only occur in the presence of carers, and investigations are repeatedly normal.

We should consider maltreatment when there are behavioural or emotional concerns, such as:

– sudden changes in behaviour,

– extreme fear, withdrawal, or aggression,

– self-harm or eating problems without a clear cause,

– sexualised behaviour that is not age appropriate,

– repeated self-harm, and ongoing wetting or soiling not explained by a medical condition.

We should also consider maltreatment when there are concerning parent–child interactions, including:

– hostility, rejection, or lack of emotional warmth,

– unrealistic expectations of the child,

– and refusal to allow the child to speak alone when appropriate.

Running away from home or living away from caregivers without agreement should also raise concern.

And to end, the key messages for us are that we should follow safeguarding procedures and seek advice early. A pattern over time is often more important than a single event and we should trust our professional judgement and discuss concerns if we are unsure.

Remember that this is not an exhaustive list, but a summary of some relevant cases to be aware of.

So that is it, a review of the NICE updates relevant to primary care.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/ndAus37PfsE

The video on hepatitic pattern abnormal LFTs can be found here:

·      https://youtu.be/rIX46swVSfg

This episode refers to guidelines on the management of abnormal liver function tests by the British Society of Gastroenterology. Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by them.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I cover what to do when in respect of an isolated high bilirubin with otherwise normal liver function tests, always focusing on what is relevant in Primary Care only.  

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

My summary guide can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mQ8MRxaNYnA1_pzh?e=H2U7rS

The resources consulted can be found here:

BSG- British Society of Gastroenterology:

·      bsg.org.uk/clinical-resource/guidelines-on-abnormal-liver-blood-tests

·      Guidelines on the management of abnormal liver blood tests (bsg.org.uk)

o  First published on:

o  BMJ article:

o  Guidelines on the management of abnormal liver blood tests | Gut (bmj.com)

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to cover what to do when we encounter an isolated high bilirubin with otherwise normal liver function tests, always focusing on what is relevant in Primary Care only.

This episode is based on the British Society of Gastroenterology guidelines on abnormal Liver function tests. A link to it is in the episode description.

Right, let’s jump into it.

And let’s start by remembering that there are three common patterns of abnormal liver function tests or LFTs:

1. An isolated raised bilirubin with otherwise normal liver tests, which is what we will concentrate on today.
2. A cholestatic pattern, normally showing a high ALP and GGT.
3. And a hepatitic pattern, with a raised ALT and AST indicating hepatocellular injury. By the way, if you are interested in finding out more about this particular type, make sure to watch the corresponding episode on this channel. The link is in the episode description.

Let’s also remember that bilirubin is the by-product of the breakdown of haemoglobin. When red blood cells are broken down, bilirubin is produced and released into the bloodstream. It exists in two forms: unconjugated bilirubin and conjugated bilirubin. Unconjugated bilirubin is water-insoluble and travels to the liver bound to albumin. Once in the liver, it is converted into conjugated bilirubin, making it water-soluble so it can be excreted into bile.

A high unconjugated bilirubin level is usually due to increased production, as in haemolysis, or reduced conjugation within the liver. A high conjugated bilirubin level, on the other hand, is normally due to liver disease or biliary obstruction, where the liver is unable to process or excrete bilirubin normally.

Many path labs will routinely report only the total bilirubin, but they will provide a breakdown into conjugated and unconjugated fractions if the level is abnormal or if it is specifically requested.

Under normal circumstances, the majority of bilirubin should be conjugated. Therefore, if most of the bilirubin is unconjugated, and there is no evidence of haemolysis, the cause is almost always Gilbert’s syndrome. In Gilbert’s syndrome, the enzyme responsible for conjugating bilirubin has reduced activity. As a result, unconjugated bilirubin accumulates, often fluctuating with fasting, stress, illness, or dehydration. Importantly, it is not associated with liver disease or ill health, and patients should be fully reassured that it is a benign lifelong condition.

But we will come back to that a little later.

How do we manage these patients?

When we manage patients with any abnormal liver function tests, we must start by recognising red flags that require urgent action. According to the BRITISH SOCIETY OF GASTROENTEROLOGY guidelines, if there are signs of synthetic liver failure – for example, unexplained clinical jaundice, a low albumin, or a raised INR – or if there is a suspicion of malignancy, such as unexplained weight loss or marked cholestasis, then these patients should be urgently referred or admitted for specialist assessment.

For patients whose only abnormality is an isolated raised bilirubin, and who have no worrying clinical signs, we can follow a more measured primary care approach:

1. First, we will request a full blood count (FBC) and repeat liver function tests (LFTs) on a fasting sample, asking specifically for the breakdown of conjugated and unconjugated bilirubin.
2. The repeat sample should be fasting because in conditions like Gilbert’s syndrome the unconjugated bilirubin tends to rise further when the liver’s conjugating capacity is challenged.

So, why does fasting raise bilirubin in Gilbert’s syndrome?

Firstly, because there is reduced hepatic energy availability. During fasting, blood glucose falls and the liver prioritises essential metabolic functions. Bilirubin conjugation is not a high-priority process, so the already-reduced enzyme activity present in Gilbert’s syndrome becomes even less effective.

Secondly, there is increased bilirubin production because fasting slightly increases the breakdown of haemoglobin and other haem-containing proteins, increasing bilirubin entering the system.

And thirdly, there is reduced hepatic uptake of bilirubin from the bloodstream because of changes in liver blood flow and transporter activity.

1. If after the repeat sample, the unconjugated bilirubin rises further on a fasting sample, and there is no evidence of haemolysis (for example, no anaemia), then Gilbert’s syndrome is the likely diagnosis.

The BRITISH SOCIETY OF GASTROENTEROLOGY guidelines emphasise that for the pattern “isolated raised bilirubin with otherwise normal liver tests”, Gilbert’s syndrome is the most common cause.

1. If there is associated anaemia, this should prompt consideration of haemolysis rather than Gilbert’s. In that scenario we should request a reticulocyte count and LDH (and possibly haptoglobin). This is because when haemolysis occurs, red blood cells are broken down more quickly than normal. This increased red-cell turnover releases large amounts of haemoglobin, which is then converted into unconjugated bilirubin. As a result, the unconjugated bilirubin rises in the bloodstream. To confirm haemolysis, we check a reticulocyte count, which will be high because the bone marrow is trying to replace the destroyed red cells, and LDH, which is released from damaged red cells and therefore increases too. We may also check haptoglobin, which binds free haemoglobin and becomes low when haemolysis is present.

If haemolysis is suspected, the patient should be referred to a haematologist, because haemolysis can have many underlying causes and diagnosing the exact cause requires specialist tests that are not usually available in primary care.

However, if the isolated raised bilirubin persists and the cause remains unclear, or if any additional liver function test abnormalities emerge, then we should follow the British Society of Gastroenterology guideline recommendation for further investigation. This may mean following the pathway for a hepatitic pattern or a cholestatic pattern, depending on the case.

But in any event:

• We should consider a liver ultrasound scan to exclude biliary obstruction or structural liver disease.
• We will consider a full liver screen. And what is a full liver screen? Apart from the ultrasound scan already mentioned, this should include hepatitis B and C screening, an autoantibody screen, serum immunoglobulins, both ferritin and transferrin saturation and, often, a coeliac screen, alpha-1-antitrypsin levels and caeruloplasmin.
• And finally, we will consider re-checking whether there is any evidence of haemolysis by repeating the reticulocyte count and LDH if haemolysis is still suspected.

And eventually, the decision will be between monitoring versus referral.

If after all of the above investigations the clinical picture remains consistent with Gilbert’s syndrome, we can continue with periodic monitoring in primary care.

On the other hand, if the isolated raised bilirubin is persistent and unexplained, we should refer the patient for specialist assessment.

So that is it, a review of an Isolated raised bilirubin with otherwise normal liver function tests.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·     https://youtu.be/w4d4qc7aHn4

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

This video also refers to a number of medical articles on ADHD published by a number of organisations (details below). Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by any of them.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I cover ADHD treatment options, especially in adults, always focusing on what is relevant in Primary Care only. The information is based on a number of published medical articles. The links to them are below.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The resources consulted can be found here:

1. NICE. Attention deficit hyperactivity disorder: diagnosis and management (NG87):

https://www.nice.org.uk/guidance/ng87?utm

2. Ostinelli EG et al. “Comparative efficacy and acceptability of pharmacological, psychological, and neurostimulatory interventions for ADHD in adults: a systematic review and component network meta-analysis.” The Lancet Psychiatry, 2025.

https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(24)00360-2/fulltext?utm

3. Gosling CJ et al. “Benefits and harms of ADHD interventions: umbrella review of systematic reviews and meta-analyses.” BMJ, 2025.

https://www.bmj.com/content/391/bmj-2025-085875?utm

4. Cortese S et al. “Attention-deficit/hyperactivity disorder (ADHD) in adults.” World Psychiatry, 2025.

https://pmc.ncbi.nlm.nih.gov/articles/PMC12434367/?utm

5. Wakelin C et al. “A review of recent treatments for adults living with attention-deficit/hyperactivity disorder.” 2023.

https://pmc.ncbi.nlm.nih.gov/articles/PMC10730462/?utm

6. Kooij JJS et al. “Updated European Consensus Statement on diagnosis and treatment of adult ADHD.” European Psychiatry, 2019.

https://pubmed.ncbi.nlm.nih.gov/30453134/?utm

https://www.cambridge.org/core/journals/european-psychiatry/article/updated-european-consensus-statement-on-diagnosis-and-treatment-of-adult-adhd/707E2A36539213CF85EACCA576F47427?utm

7. Nimmo-Smith V et al. “Non-pharmacological interventions for adult ADHD: a systematic review.” Psychological Medicine, 2020.

https://pubmed.ncbi.nlm.nih.gov/32036811/?utm

https://www.cambridge.org/core/journals/psychological-medicine/article/nonpharmacological-interventions-for-adult-adhd-a-systematic-review/538F70FB89C5B687F4A75E7431E63B38?utm

8. Mechler K et al. “Evidence-based pharmacological treatment options for ADHD in children, adolescents and adults.” Neuroscience & Biobehavioral Reviews, 2022.

https://www.sciencedirect.com/science/article/pii/S016372582100142X?utm

9. AWMF S3 Guideline. “Attention-Deficit/Hyperactivity Disorder (ADHD) in Children, Young People and Adults.” 2020.

https://register.awmf.org/assets/guidelines/028_D_G_f_Kinder-_und_Jugendpsychiatrie_und_-psychotherapie/028-045eng_S3_ADHS_2020-12-abgelaufen.pdf?utm

10. Wolraich ML et al. “Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents.” Pediatrics, 2019.

https://publications.aap.org/pediatrics/article/144/4/e20192528/81590/Clinical-Practice-Guideline-for-the-Diagnosis?utm

11. Faraone SV et al. “The World Federation of ADHD International Consensus Statement: 208 evidence-based conclusions about the disorder.” Neuroscience & Biobehavioral Reviews, 2021.

https://pubmed.ncbi.nlm.nih.gov/33549739/?utm

https://www.sciencedirect.com/science/article/pii/S014976342100049X?utm

https://www.adhd-federation.org/publications/international-consensus-statement.html?utm

12. CADDRA. Canadian ADHD Practice Guidelines, Version 4.1. 2020.

https://www.caddra.ca/canadian-adhd-practice-guidelines/?utm

13. Therapeutics Initiative. “ADHD in adults.” Therapeutics Letter 144, 2023.

https://www.ti.ubc.ca/2023/09/29/144-adhd-adults/?utm

14. May T et al. “The Australian evidence-based clinical practice guideline for ADHD.” Australian Journal of General Practice / AADPA, 2023.

https://adhdguideline.aadpa.com.au/?utm

https://pmc.ncbi.nlm.nih.gov/articles/PMC10363932/?utm

15. Coghill D & colleagues / Australian Prescriber. “Pharmacological management of attention deficit hyperactivity disorder in children and adolescents.” Australian Prescriber, 2025.

https://australianprescriber.tg.org.au/articles/pharmacological-management-of-attention-deficit-hyperactivity-disorder-in-children-and-adolescents.html?utm

16. Thapar A et al. “Attention-deficit/hyperactivity disorder.” Nature Reviews Disease Primers, 2024.

https://www.nature.com/articles/s41572-024-00495-0?utm

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to talk about ADHD treatment options, especially in adults, always focusing on what is relevant in Primary Care only.

I have based this episode on a number of published medical articles. The links to them are in the episode description.

Right, let’s jump into it.

Modern guidelines emphasise that ADHD management is multimodal — including psychoeducation, environmental adaptations, psychological interventions, and, where indicated, medication.

For children and adolescents, NICE and other guidelines recommend starting with psychoeducation and behavioural or parent training, then adding medication when impairment remains significant.

However, for adults, guidelines are very clear: medication is usually first-line when symptoms cause persistent, moderate to severe impairment, supported by psychoeducation and practical help.

So, when is medication indicated?

For children and adolescents, medication — usually methylphenidate — is recommended only when ADHD is clearly diagnosed, the impairment is significant, and non-drug approaches aren’t enough. In other words, it’s generally reserved for moderate to severe ADHD, rather than mild cases.

However, for adults, medication is indicated when there is a clear diagnosis of ADHD with symptoms present since childhood, even if they were never recognised at the time. The symptoms must be causing clinically significant impairment, and other conditions — like depression, bipolar disorder, or substance misuse — shouldn’t fully explain what’s going on. And finally, the person needs to want to try medication after discussing the risks and benefits.

Guidelines such as NICE and the European consensus explicitly state that, in adults, medication is the main evidence-based treatment for core ADHD symptoms, offered alongside education and support.

Which medications should we use, and how effective are they?

There are two main classes.

First, stimulants, such as methylphenidate in various modified-release forms, and amphetamine formulations like lisdexamfetamine.

Second, non-stimulants, including atomoxetine, guanfacine—which has more evidence in children and adolescents—and others like bupropion, clonidine, and viloxazine, though adult data for these are more limited.

A landmark meta-analysis of randomised trials found that, in adults, amphetamines produced the largest improvements in clinician-rated symptoms. They were at least as well tolerated as methylphenidate, and more effective than atomoxetine and modafinil.

A recent BMJ umbrella review, which examined multiple meta-analyses, concluded that in the short term—up to about twelve weeks—both stimulants and some non-stimulants produce medium to large reductions in symptoms. Evidence beyond one year is more limited, but it does not suggest a loss of effect.

The World Federation of ADHD consensus summarises this by stating that ADHD medication is clearly effective for reducing symptoms, and that stimulants are more effective than non-stimulants.

Are there any long-term benefits of regular medication use?

Well, in terms of symptom control, longitudinal studies and reviews show that continued medication is associated with sustained improvements in symptoms and functioning in both children and adults, as well as improvements in overall life satisfaction.

Furthermore, there is also evidence for broader life outcomes. The World Federation of ADHD consensus concluded that drug treatment is linked to substantial reductions in a range of adverse outcomes, including transport accidents, substance misuse and cigarette smoking, educational underachievement, depression and suicide attempts, and even criminal behaviour and teenage pregnancy.

Taken together, this suggests that for many patients, long-term use of ADHD medication does more than just reduce symptoms. It appears to lower the risk of serious negative life events and improve quality of life.

And now, let’s touch briefly on non-drug treatments.

For children and adolescents, guidelines emphasise psychoeducation and parent-training programmes, school-based interventions, and behavioural approaches such as reward systems and structured routines.

For adults, the main non-drug options include psychoeducation about ADHD, CBT tailored to ADHD, that is, focusing on time management, planning, and emotional regulation, and finally, coaching and skills training, along with workplace or academic adaptations.

So how effective are these approaches? A systematic review of non-pharmacological interventions in adults found that particularly CBT and skills training produce small to moderate improvements in symptoms and functioning.

However, the World Federation consensus is quite blunt: non-medication treatments are generally less effective than medication for core ADHD symptoms, although they remain very useful for addressing residual difficulties once medication has been optimised.

Now that we know the benefits of treatment, what are the possible side effects, and how do we monitor treatment?

Common side effects of both stimulants and atomoxetine include reduced appetite and weight loss, sleep disturbances, mild increases in heart rate and blood pressure, headache, dry mouth, gastrointestinal symptoms, and occasionally irritability or mood lability.

There are also possible psychiatric adverse effects. Rarely, stimulants and atomoxetine can precipitate anxiety, irritability, mood elevation, or even psychotic symptoms, particularly in vulnerable people or at higher doses. To reduce this risk, guidelines recommend careful monitoring, dose adjustments, and stopping the medication if significant symptoms appear.

Overall, the World Federation consensus concludes that “the adverse effects of medications for ADHD are generally mild and can be addressed by changing the dose or the medication,” while the consequences of untreated ADHD are often serious and long-lasting.

In terms of cardiovascular safety, for most people without pre-existing heart disease, stimulants and atomoxetine cause only small increases in blood pressure and heart rate, and serious cardiovascular events are rare.

So what does this mean in practice? Guidelines recommend taking a brief cardiac and family history, checking blood pressure and pulse, and making sure there are no red flags before starting medication. If someone has a known heart condition, or if the assessment raises any concerns, then we should ger cardiology input before prescribing.

Regarding misuse, diversion, and dependency we need to be aware that stimulants have abuse potential, particularly in fast-acting formulations, which is why long-acting preparations and careful monitoring are recommended. However, the consensus statement notes that while stimulants can be diverted or misused, therapeutic doses in people with ADHD are actually associated with lower rates of later substance-use disorders, not higher.

In summary, for adults with significant ADHD, medication is the most effective treatment for core symptoms. When used long-term with proper monitoring, it’s associated not only with better concentration, but with lower rates of other serious negative outcomes. At the same time, side effects are common but usually mild and manageable.

So that is it, a review of ADHD treatment options.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/aDbEwtY3hw0

This video refers to a number of medical articles on ADHD published by a number of organisations (details below). Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by any of them.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I cover ADHD increasing incidence, especially in adults, always focusing on what is relevant in Primary Care only. The information is based on a number of published medical articles. The links to them are below.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The resources consulted can be found here:

1.   Shah P et al. “Potential impact of social media and COVID-19 restrictions on adult attention-deficit rates.” BJPsych Bulletin, 2025.

https://pubmed.ncbi.nlm.nih.gov/41208391/

2.   Adult Psychiatric Morbidity Survey 2023–24, Chapter 9: ADHD (NHS England, 2024).

https://digital.nhs.uk/data-and-information/publications/statistical/adult-psychiatric-morbidity-survey/survey-of-mental-health-and-wellbeing-england-2023-24/attention-deficit-hyperactivity-disorder?utm

3.   McKechnie DGJ et al., UK primary-care database study, 1998–2018 – summarised by NIHR as “Significant rise in ADHD diagnoses in the UK” (2023).

https://www.nihr.ac.uk/news/significant-rise-adhd-diagnoses-uk?utm

4.   Gimbach S et al. “ADHD medicine consumption in Europe after COVID-19.” Public Health / Pharmacoepidemiology, 2024.

https://pmc.ncbi.nlm.nih.gov/articles/PMC10854136/?utm

5.   Rzeszutek M et al. “Global Trends in ADHD Medication Use: Multiple Contexts and Populations.” Journal of Clinical Medicine, 2025.

https://www.mdpi.com/2077-0383/14/20/7338?utm

6.   Martin AF et al. “The changing prevalence of ADHD? A systematic review.” Journal of Affective Disorders, 2025.

https://www.sciencedirect.com/science/article/pii/S0165032725008638?utm

7.   Staley BS et al. “ADHD Diagnosis, Treatment, and Telehealth Use in Adults — United States, 2023.” MMWR (CDC), 2024.

https://www.cdc.gov/mmwr/volumes/73/wr/mm7340a1.htm?utm

8.   Butt DA et al. “Prevalence and Incidence Trends of Attention Deficit Hyperactivity Disorder in Canada.” Canadian Journal of Psychiatry, 2024.

https://journals.sagepub.com/doi/10.1177/07067437231213553?utm

9.   Therapeutics Initiative. “ADHD in adults.” Bulletin 144, 2023.

https://www.ti.ubc.ca/2023/09/29/144-adhd-adults/?utm

10. Bradlow RCJ et al. “Adult attention deficit hyperactivity disorder in Australia: how its current commercial model for diagnosis and treatment is encouraging misdiagnosis.” Medical Journal of Australia, 2025.

https://www.mja.com.au/journal/2025/223/8/adult-attention-deficit-hyperactivity-disorder-australia-how-its-current?utm

11. Woon LSC et al. “Online interest in ADHD predicts ADHD medication prescriptions in Australia from 2004 to 2023: a time-series analysis revealing COVID-19-related acceleration.” (2025).

https://pmc.ncbi.nlm.nih.gov/articles/PMC12138142/?utm

12. May T et al. “The Australian evidence-based clinical practice guideline for ADHD.” Australian Journal of General Practice / Australian guidelines consortium, 2023.

https://pmc.ncbi.nlm.nih.gov/articles/PMC10363932/?utm

13. Cortese S et al. “Attention-deficit/hyperactivity disorder (ADHD) in adults.” World Psychiatry / World Psychiatric Association, 2025. PMC+2Wiley Online Library+2

https://pmc.ncbi.nlm.nih.gov/articles/PMC12434367/?utm

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to talk about the increasing number of ADHD diagnoses, especially in adults, always focusing on what is relevant in Primary Care only.

I have based this episode on a number of published medical articles. The links to them are in the episode description.

Right, let’s jump into it.

And the first question to ask is: why are we covering this topic now?

You may be aware that in the UK, the government has recently announced a formal review into surging mental-health and neurodevelopmental diagnoses, including ADHD and autism. This has sparked media coverage and public debate: are we seeing a real increase in ADHD, or are normal struggles being unnecessarily medicalised?

In other words, is this an epidemic of overdiagnosis, or does the rise in cases simply reflect that we’re starting to catch up with reality?

So now, it’s more important than ever to look at what the research actually shows, especially around adult ADHD diagnoses. And although we in primary care are not directly responsible for the full diagnosis and treatment process, the way we assess and support these patients at their first point of contact can make a huge difference. It shapes how they experience their care, whether they feel understood, and whether they receive the guidance and support they need.

Let’s start by reminding ourselves that attention-deficit/hyperactivity disorder, or ADHD, is a neurodevelopmental condition that affects a person’s ability to regulate attention, manage impulses, and maintain consistent levels of activity.

In adults, ADHD often looks very different from the stereotype of a hyperactive child. Adults tend to present with chronic distractibility, difficulty organising tasks, emotional impulsivity, forgetfulness, restlessness, and problems sustaining attention at work or in relationships. These symptoms can have real-world consequences, including difficulties with work and relationships, financial problems, and a persistent sense of underachievement.

The consensus is that ADHD is highly heritable and is associated with higher rates of anxiety, depression, and substance misuse. It’s also linked to measurable differences in executive brain function. And by this, we mean that the prefrontal cortex — the area responsible for focus, planning, impulse control, and emotional regulation — works differently in people with ADHD. Brain-imaging studies have repeatedly shown altered activity in this area.

So what this really means is that ADHD symptoms aren’t just behavioural. They reflect real differences in brain function.

Importantly, ADHD is not a condition people usually “grow out of.” For around two-thirds of children with ADHD, symptoms continue into adulthood, although sometimes in a more subtle or internalised form.

So, why are adult ADHD diagnoses increasing?

Research shows that adult ADHD is now better recognised. Historically, many adults — especially women — were simply missed in childhood because their symptoms were less disruptive, or because diagnostic criteria were focused on school performance rather than adult functioning.

A recent study from the UK found that adult referrals for ADHD assessment increased threefold between 2019 and 2023, with peaks during and after the COVID-19 pandemic. This is likely because the pandemic disrupted daily routines and removed coping structures, making previously manageable symptoms more difficult, and prompting more adults to seek help.

As diagnoses have increased, some people — including medical professionals — have expressed concerns that the condition might be overdiagnosed. After all, clinicians have always been wary of patients self-diagnosing, and the fact that some ADHD assessments rely on self-reported symptoms can create doubts for those who aren’t familiar with how structured and evidence-based these assessments actually are.

The numbers are stark. A large 20-year UK primary-care cohort study found that recorded ADHD diagnoses increased roughly twenty-fold, while ADHD medication prescribing rose fifty-fold. Some of the biggest proportional increases were seen in adults, particularly men aged 18 to 29.

Is this surprising? Not necessarily. ADHD is more common than many people realise. Multiple published reviews estimate the prevalence in children and adolescents to be between two and eight percent, and a major 2023 re-analysis placed it at 5.41 percent.

However, many studies showing steep increases in diagnosis have still reported prevalence rates well below this expected five percent.

Additionally, the most recent Adult Psychiatric Morbidity Survey shows that in England, although 13.9 percent of adults screened positive for probable ADHD, only 1.8 percent reported receiving a formal diagnosis. That suggests that many adults with ADHD still remain unidentified.

So, while there may be some isolated overdiagnosis, overall, the evidence suggests that ADHD remains underdiagnosed — particularly in adults.

What about internationally? Have there been similar rises across other Western countries?

The short answer is yes. Across Europe and other high-income countries, studies consistently show that ADHD medication use among adults has grown sharply, often by several hundred percent over the last decade, with a particularly striking rise in adult women. And a recent analysis in the United States showed that six percent of adults report a current ADHD diagnosis, and importantly, about half of them were first diagnosed in adulthood.

This increase in diagnosis, which may simply reflect that we are catching up with the reality of neurodivergence. Factors contributing to this better recognition include:

• greater understanding that ADHD persists into adulthood,

• the use of more adult-appropriate diagnostic criteria, and

• higher public awareness with reduced stigma.

What does an ADHD diagnosis actually mean for patients?

For many adults, receiving a diagnosis finally helps them make sense of lifelong challenges. And research consistently shows that after diagnosis, people often experience:

• improved self-esteem,

• better workplace functioning,

• more stable relationships, and

• a reduced risk of comorbid anxiety and depression.

It also gives them the opportunity to seek treatment. Treatment for ADHD is multimodal and includes:

• education and coaching,

• CBT,

• lifestyle structuring,

• and, when appropriate, medication — which remains one of the most effective interventions for ADHD symptoms in adults.

And by the way, if you want to learn more about ADHD treatment options, stay tuned — a full video on ADHD treatment is coming soon.

So that is it, a review of the increased number of ADHD diagnoses.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/dZpq3W-lkSQ

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in November 2025 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The Full NICE News bulletin for November 2025 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2025-11-01&to=2025-11-30&ndt=Guidance&ndt=Quality+standard

The new guideline on suspected sepsis in people aged 16 or over can be found here:

·      https://www.nice.org.uk/guidance/ng253

The new guideline on suspected sepsis in under 16s can be found here:

·      https://www.nice.org.uk/guidance/ng254

The new guideline on suspected sepsis in pregnant or recently pregnant people can be found here:

·      https://www.nice.org.uk/guidance/ng255

The visual summary for suspected sepsis: evaluation and management, all ages, settings and population groups can be found here:

·      https://www.nice.org.uk/guidance/ng253/resources/suspected-sepsis-managing-and-evaluating-risk-all-settings-pdf-15494830813

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in November 2025, focusing on what is relevant in Primary Care only.

And this time we have three brand-new guidelines on a single topic: Sepsis. There are three separate guidelines because each one focuses on a different group: people aged 16 and over, children and young people under 16, and those who are pregnant or recently pregnant.

Right, let’s jump into it.

And we will start by saying that we will focus on the recommendations for people over 16 but I’ll also point out what’s different for the under-16 group and for pregnant people.

If infection is suspected, the first question to ask ourselves is: Could this be sepsis? And then assess for a potential source, for risk factors, and for any signs of clinical concern in circulation, breathing, or behaviour, ideally using a structured system.

The main 6 observations that we should assess are: temperature, heart rate, respiratory rate, blood pressure, level of consciousness and oxygen saturation. However, we need to remember that some groups of people with sepsis may not develop a raised temperature and that, in terms of oximetry, poor peripheral circulation due to shock can make peripheral oxygen saturation difficult to measure. Additionally, we need to be aware that some pulse oximeters can underestimate or overestimate readings, especially if the level is borderline and that overestimation has been reported in people with dark skin.

Additionally, we should examine for:

• mottled or ashen appearance
• cyanosis
• skin rashes, particularly non-blanching petechial or purpuric rashes
• and any breach of skin integrity as the source of infection

We should always keep in mind groups who are more vulnerable: people over 75, those with frailty or co-morbidities, learning disabilities, immunosuppression, indwelling lines or catheters, recent surgery or invasive procedures, and those with adverse social or economic factors that may delay presentation.

In hospital or ambulances, the National Early Warning Score 2, or NEWS2, is recommended. NEWS2 measures the same six values, temperature, heart rate, respiratory rate, blood pressure, level of consciousness and oxygen saturation.  and then assigns points based on how abnormal they are. I will not go through every score and its clinical implications but there is NEWS2 calculator app reproduced from the Royal College of Physicians that I would really recommend downloading.

However, in primary care we can consider NEWS2 or any other structured observation tool. The guideline gives us a set of criteria to assess the risk of severe illness. There are high risk and moderate risk criteria. The high-risk criteria for people over 16 are as follows:

·      A new altered mental state

·      A respiratory rate of 25 breaths per minute or more

·      New need for oxygen to maintain saturation more than 92% (or more than 88% in chronic hypercapnic respiratory failure)

·      A Systolic BP of 90 mmHg or less or more than 40mmHg below normal

·      A heart rate of more than 130 beats per minute

·      Not passed urine in previous 18 hours, or for catheterised patients, passed less than 0.5 ml/kg of urine per hour

·      Mottled or ashen appearance

·      Cyanosis and

·      A non-blanching petechial or purpuric rash

These are the high-risk criteria only. For simplicity, I will not go through all the moderate risk criteria, but they are similar to the high-risk ones but with values slightly less abnormal.

Once sepsis is suspected, for primary care, the key point is to arrange rapid referral or admission to hospital. In remote or rural areas where transfer exceeds one hour, the guideline states that systems should exist so GPs can give the first dose of antibiotics when high-risk criteria are met.

For borderline or uncertain cases, we should provide clear safety-netting, and ensure patients and carers understand warning symptoms and when to seek help.

Let’s quickly touch on sepsis in children.

Risk stratification for children is a lot more complex and is based on age bands — under 5, 5 to 11, and 12 to 15 — each with its own physiological thresholds. Because of the complexity, I will not go through all the high-risk criteria here, but we need to remember that severity is judged not just on vital signs, but on age-appropriate risk criteria combined with history, examination and clinical judgement.

Adult early-warning scores such as NEWS2 should not be applied to children.

If a child meets any high-risk criterion, they require urgent admission to hospital.

For lower-risk children, we must still decide between safe management in the community with safety-netting or urgent admission if concerns arise. For this, communication must be tailored to the child and their carers, with clear explanations as to what to do if the situation does not improve.

Let’s now move to people who are pregnant, or within six weeks postpartum. They fall under a separate guideline because pregnancy changes physiology and the pattern of infection.

For pregnant or recently pregnant people, NEWS2 is not appropriate either. Instead, we should use a pregnancy-specific risk table with high-risk, moderate-to-high-risk, and low-risk criteria.

These criteria include the usual physiological markers but they use pregnancy-specific thresholds and they also emphasise obstetric sources of infection, such as endometritis, wound infections, urinary infection, retained products, and mastitis.

Again, I will not go through all the criteria here but NICE has produced a visual summary of the risk criteria for all groups. The link to it is in the episode description.

Going back to the assessment of suspected sepsis for people that are pregnant or recently pregnant, if any high-risk criterion is present, emergency admission will be required.

For us in primary care, the key points are that pregnancy or up to six weeks postpartum automatically places the patient in a higher-risk group, we must use pregnancy-specific criteria rather than adult scores, the threshold for calling an ambulance and pre-alerting services is lower, and finally, we should always think of obstetric sources of infection alongside the usual ones.

So that is it, a review of the NICE updates relevant to primary care.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/rIX46swVSfg

This episode refers to guidelines on the management of abnormal liver function tests by the British Society of Gastroenterology and a number of NHS organisations in the UK. Here I focus on the hepatitic pattern of abnormal LFTs. Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by them.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review the interpretation, initial follow up management, of adults presenting with a hepatitic pattern in their LFT’s, always focusing on what is relevant in Primary Care only.

This episode is based on the British Society of Gastroenterology guidelines on LFTs. A link to it is in the episode description..

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

My summary guide can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mQ8MRxaNYnA1_pzh?e=H2U7rS

The resources consulted can be found here:

BSG- British Society of Gastroenterology:

·      bsg.org.uk/clinical-resource/guidelines-on-abnormal-liver-blood-tests

·      Guidelines on the management of abnormal liver blood tests (bsg.org.uk)

o  First published on:

o  BMJ article:

o  Guidelines on the management of abnormal liver blood tests | Gut (bmj.com)

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to go through the interpretation, initial follow up management, of adults presenting with a hepatitic pattern in their LFT’s, always focusing on what is relevant in Primary Care only.

This episode is based on the British Society of Gastroenterology guidelines on LFTs. A link to it is in the episode description.

Right, let’s jump into it.

We have to start by remembering that liver disease develops silently and at earlier stages liver enzymes may be normal, and, if they are high, the degree of abnormality is not necessarily related to the severity of the underlying condition.

We also need to remember that AST and ALT are enzymes present in the liver cells and the levels increase in response to cell injury or death. ALT is considered more liver-specific while AST is also present in skeletal, cardiac and smooth muscle and so may be elevated in patients with an MI or myositis.

An AST:ALT ratio of >1 is a non-invasive marker of liver fibrosis. In early liver disease, AST and ALT can be normal, but the high AST:ALT ratio is usually present even if both values are normal.

So, what should we do when confronted by abnormal LFTs?

First of all, we should not think that the extent of abnormality of the LFTs correlates necessarily with the severity of the problem. Common conditions leading to chronic liver disease like NAFLD, and hepatitis C are frequently associated with only mild or moderate LFT abnormalities.

Also, we should not think that the duration of the abnormal LFTs is a reflection of clinical significance, so repeating the LFTs hoping that they will improve is not necessarily the way to go. We need to remember that in many chronic liver diseases such as hepatitis C and NAFLD, the LFTs returning to normal do not necessarily imply the resolution of the disease.

Therefore, the recommendation is that most patients with abnormal LFTs should have a full liver screen irrespective of level and duration of the abnormality.

What is a full liver screen?

This should include an USS, hepatitis B and C screening, an autoantibody screen, serum immunoglobulins, both ferritin and transferrin saturation and, often, a coeliac screen, alpha-1-antitrypsin levels and caeruloplasmin.

And finally, let’s remember that there are three common patterns of abnormal LFTs:

1. An Isolated raised bilirubin with otherwise normal liver tests
2. A Cholestatic pattern: normally showing a high ALP and GGT
3. A Hepatitic pattern: with a raised ALT and AST indicating hepatocellular injury, like, for example, viral hepatitis, NAFLD, and ARLD. The hepatitis pattern is the section that we will concentrate on today.

The three most common causes of liver disease are alcohol-related liver disease, non-alcoholic fatty liver disease and viral hepatitis.

How do we manage these patients?

First of all, if there are signs of synthetic liver failure like unexplained clinical jaundice, a low albumin or a high INR or if there is suspicion of malignancy, for example because of weight loss or marked cholestasis, we should urgently refer or admit the patient.

If the patient has a hepatitic picture with a high ALT and AST, the management will depend on the level of liver fibrosis, which we can estimate using non-invasive fibrosis markers.

The majority of patients presenting with a hepatitic pattern will have either NAFLD or ARLD.

So let’s start with NAFLD.

Following a liver USS, for patients with NAFLD or liver disease of unknown cause, we will estimate the risk of fibrosis using the FIB4 or NAFLD fibrosis score. These scores have cut off points for low, intermediate and high risk of fibrosis.

If there is a low risk of advanced fibrosis, we will just manage the risk factors in Primary Care and reassess periodically, generally every 2 to 5 years. In primary care, the treatment for NAFLD is weight loss, alcohol advice, the reduction of cardiovascular risk and the management of co-morbidities.

If the risk of fibrosis is intermediate, these patients should have second-line tests such as an enhanced liver fibrosis blood test, also known as an ELF test, or imaging such as a FibroScan or elastography.

However, patients with very high scores representing a high risk of fibrosis, should be referred to hepatology without waiting to do an ELF test, Fibroscan or elastography.

Let’s now look at ARLD. For patients with ARLD we will assess their alcohol intake, using the AUDIT C or the full AUDIT questionnaire if necessary. Depending on the severity of the alcohol intake, we will give them a brief intervention, refer them to alcohol services or to hepatology for further investigations.

The treatment of ARLD is to stop drinking harmfully, and for many this usually means complete abstinence. Weight loss sometimes also helps because there is a synergy between alcohol and obesity. For example, when the BMI is >35, the risk of liver disease doubles for any given alcohol intake.

But, finally, what should we do if the patient has a hepatitic pattern with a high ALT and AST without an obvious cause, that is, when the liver screen is normal and there is no evidence of NAFLD on USS or excess alcohol?

In those cases, we will need to re-examine the history to exclude potential drug-induced causes. Also, ultrasound is only sensitive for steatosis when hepatocytes are more than 30% steatotic so patients with milder steatosis might have a normal USS. So, if these patients are obese or have metabolic risk factors and we suspect that they may still have NAFLD despite the normal USS, we should assess them in accordance with the NAFLD pathway.

But at the end of the day, if AST or ALT remain high without an obvious cause, we will need to refer them to secondary care for further investigations.

So that is it, a review of abnormal LFTs with a hepatitic pattern.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

The video version of this podcast can be found here:

·      https://youtu.be/goK_Q4P2qpk

This video refers to guidelines produced by a number of organisations (details below). Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by any of them.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I neutropenia always focusing on what is relevant in Primary Care only. The information is based on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

My summary of the guidance consulted can be found here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mQ4ZjYGRH1wkGBdc?e=Zuxx84

The resources consulted can be found here:

·      Camden CCG guidance: 1456246258-2f3891e610beaa6533f2c0ad7866e776.pdf(Review) - Adobe cloud storage

·      Manchester Adult anaemia guide: https://acrobat.adobe.com/id/urn:aaid:sc:EU:f96fe528-0a47-457c-b29a-a7efb87221e0

·      Manchester Haematology GP guide: https://mft.nhs.uk/app/uploads/2021/02/MFT-Haematology-GP-Pathway-Guide-v4-11.2.21.pdf

·      King’s Health Partners: https://www.kingshealthpartners.org/assets/000/002/294/KCH_-_king_s_health_partners_-_quick_guide_to_haematology_original.pdf

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to cover neutropenia, including initial assessment, follow up and management, always focusing on what is relevant in Primary Care only.

I have based this episode on Haematological guidance by Camden CCG, Manchester Foundation Trust and King’s Health Partners. The links to them are in the episode description.

Right, let’s jump into it.

Neutrophils are the most numerous subtype of white blood cell and they are the body’s first responders to bacterial infections.

Neutropenia is when the neutrophil count is low. A normal neutrophil count in adults ranges from 2.0 to 7.5. However, an isolated low neutrophil count is extremely common in clinical practice. A result between 1.5 and 2.0 × 10⁹/l, while technically below the normal reference range, is rarely clinically significant. Many healthy people fluctuate in this borderline range due to factors such as minor viral infections, recent exercise, or simply natural day-to-day variation in blood counts.

We also have to remember that normal ranges differ across populations. People of Afro-Caribbean or Middle Eastern heritage often have a normal baseline neutrophil count between 1.0 and 1.8 × 10⁹/l. This is known as constitutional or ethnic neutropenia, which is of no clinical consequence. It is a benign, lifelong finding and does not increase susceptibility to infection. For these patients, referral is usually only needed if the neutrophil count falls below 1.0 × 10⁹/l on repeat testing.

For everybody else and for the purpose of this episode, we will define neutropenia as a neutrophil count below 1.5.

Possible causes of neutropenia are as follows:

• first we have drugs: such as phenytoin, carbimazole, antipsychotics, and co-trimoxazole, which can suppress neutrophil production in the bone marrow or trigger immune-mediated neutrophil destruction. Some drugs are directly toxic to the bone marrow, while others induce antibody formation against neutrophils.

• then we have Malignancy: including conditions like myeloma or any cancer that infiltrates the bone marrow. This reduces the marrow’s ability to produce neutrophils. Additionally, chemotherapy and radiotherapy further compound this by damaging rapidly dividing cells, leading to predictable and sometimes profound neutropenia.

• Also Vitamin B12 and folate deficiency: which impair DNA synthesis. Because neutrophils and their precursors divide rapidly, they are particularly sensitive to this.

• then we have Iron deficiency: which reduces the efficiency of haematopoiesis in general. Although iron deficiency is normally associated with anaemia, iron is also required for normal development of all blood cell lines, including neutrophils. Severe or prolonged deficiency can therefore lead to mild neutropenia.

•Another cause ca be Autoimmune diseases: which can cause neutropenia through immune-mediated destruction by autoantibodies that target neutrophils or their precursors.

• then we have viral infections: including EBV, HIV, and hepatitis B and C, which can directly suppress bone marrow activity or cause redistribution of neutrophils from the bloodstream into tissues. Many other viruses also transiently inhibit neutrophil production during acute illness, making mild neutropenia very common.

• Also, another possible cause is excess alcohol: which is toxic to the bone marrow and can impair the proliferation and differentiation of myeloid precursors. Chronic alcohol use is also associated with nutritional deficiencies, particularly folate, compounding the effect on marrow function.

• then we have Liver disease and cirrhosis: which can lead to neutropenia through hypersplenism causing increased sequestration and destruction of blood cells in the spleen. Another mechanism is metabolic effect of cirrhosis on overall bone marrow function. And finally, as we have already explained there is:

• Ethnic variation: like constitutional or ethnic neutropenia in people of Afro-Caribbean and Middle Eastern descent. Again, this is a benign inherited pattern without any impairment in immune function.

How should we manage these patients? We should send the patient to hospital as an emergency if:

• There is any evidence of sepsis, because neutropenic patients are at high risk of overwhelming infection. This means they can deteriorate rapidly, often without the typical signs of infection.

• Additionally, we should also send the patient to hospital as an emergency if the neutrophil count is below 1.0 × 10⁹/l and any of the following factors are present:

– First, if the patient is on chemotherapy.

This is because chemotherapy-induced neutropenia can progress quickly, and these patients are at particularly high risk. In this setting, infection can become severe within hours leading to sepsis.

– Also, if there is lymphadenopathy because enlarged lymph nodes raise concern for an underlying haematological malignancy, such as lymphoma or leukaemia, or for a significant viral infection causing significant bone marrow involvement.

– Also if there is splenomegaly because an enlarged spleen suggests increased sequestration and destruction of blood cells, or infiltration by malignancy or infection. Splenomegaly with neutropenia can be suggestive of serious conditions such as myeloproliferative disorders, autoimmune cytopenias, or advanced liver disease with hypersplenism.

– And finally, we should also send the patient to hospital as an emergency if the neutrophil count is below 1.0 × 10⁹/l if there are other cytopenias.

For example, if anaemia or thrombocytopenia is also present, this points toward a significant bone marrow problem which increases the risk of complications.

We should make an urgent haematological referral on a cancer pathway if:

• The neutrophil count is below 0.5 × 10⁹/l and the patient is otherwise well.

This is because a neutrophil count this low is concerning even in the absence of symptoms. Counts below 0.5 significantly increase the risk of serious infection, and they also raise the possibility of an underlying bone marrow disorder. Conditions such as acute leukaemia, myelodysplastic syndromes, or bone marrow infiltration can initially present with isolated severe neutropenia before other clinical signs appear.

If the neutrophil count is above 0.5 × 10⁹/l and the patient is clinically well, we can safely take a stepwise approach. The first action is to repeat the blood test within one week, as many cases of mild neutropenia are transient. At the same time, and as part of the initial work-up, which other investigations should we request?

We should investigate the underlying cause by organising the following tests:

• As already mentioned, a repeat full blood count.

This in order to confirm whether the neutropenia is sustained and to check for other full blood count abnormalities.

• A blood film: which can identify abnormal cell morphology, immature cells, or blasts suggestive of bone marrow disease. It can also help detect features consistent with infection, nutritional deficiency, or autoimmune processes.

• Vitamin B12 and folate: because as we said earlier, deficiency can lead to ineffective neutrophil production.

• Ferritin and iron studies: given that iron deficiency not only causes anaemia, but can also reduce neutrophil production.

• Autoimmune screen because some autoimmune conditions can cause immune-mediated destruction of neutrophils or affect bone marrow function.

• HIV testing: because HIV can lead to neutropenia through direct bone marrow suppression, chronic immune activation, or associated infections. In these cases, HIV treatment can reverse the neutropenia and improve overall immunity.

• and finally, we should also request Hepatitis B and C serology: given that chronic viral hepatitis can impair bone marrow function and is also associated with splenomegaly, hypersplenism, and autoimmune cytopenias.

After we have done these tests, if the patient is well and the cause of the neutropenia remains unknown, our next steps will depend on the degree and persistence of the low neutrophil count.

Firstly, if the neutrophil count remains below 1.0 × 10⁹/l we will refer urgently to outpatient haematology. This is because even in the absence of symptoms, this level carries a meaningful risk of infection and warrants specialist assessment.

If the neutrophil count is between 1.0 and 1.5 × 10⁹/l, we will monitor the full blood count for 4–6 weeks. This is because many cases in this borderline range are temporary, and monitoring over several weeks helps determine whether the neutropenia is improving, stable, or worsening.

Then we will refer to haematology routinely if any of the following occur:

– First, if the neutrophil count remains below 1.5 × 10⁹/l

(or below 1.0 × 10⁹/l in African-Caribbean patients, due to constitutional neutropenia). This is to rule out the possibility of a chronic underlying cause.

– Also if there are other full blood count abnormalities suggesting that more than one blood cell line may be affected, raising concern for broader marrow pathology.

– and finally, if there is a history of infections or ulcers. This is because recurrent infections, mouth ulcers, or delayed healing are clinical signs that the neutropenia may be functionally significant, even if the absolute count is only mildly reduced. These symptoms suggest impaired neutrophil activity or insufficient neutrophil reserves, and they strengthen the case for specialist review.

So that is it, a review of the initial assessment and management of neutropenia.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.