It takes years to develop and test new treatments, so it is exciting when they finally reach clinical practice. This issue of Guidelines in Practice includes two articles that discuss new treatments: mechanical thrombectomy for acute ischaemic stroke, and immunotherapy as a cancer treatment. Although neither of these therapies are central to primary care, there are aspects of both treatments that primary care clinicians should be aware of.

Mechanical thrombectomy is an interventional procedure that aims to remove an obstructing blood clot from arteries in the brain to restore blood flow and minimise tissue damage. Dr Dipankar Dutta describes how the procedure is performed, what the patient selection criteria are, and how thrombectomy services are commissioned in the UK.

Mechanical thrombectomy can only be carried out in specialist centres and, as with all stroke treatments, timely access to treatment is crucial to achieving the best patient outcomes. Primary care clinicians may encounter patients with suspected acute strokes within the time window for successful treatment, and these patients should be directed to their nearest stroke centre via 999 emergency. The article includes a useful algorithm that outlines the patient pathway. After reading the article, test your updated knowledge using the multiple-choice questions included in this issue.

Checkpoint inhibitors (CPIs) appear to be revolutionising cancer treatment because they have shown activity in a range of cancers, including some that previously had limited treatment options and poor prognoses. In this month’s Top tips article, Dr Anna Olsson-Brown and Dr Nicola Harker explain how CPIs work, how to recognise CPIs by name, and the toxicities and side-effects that patients being treated with CPIs can experience.


Top tips: cancer immunotherapy

Dr Anna Olsson-Brown and Dr Nicola Harker

In many cases, CPIs are well tolerated and patients feel well while receiving treatment. The main toxicities associated with CPIs are immune‑related adverse events (irAEs), some of which are symptomatic and some asymptomatic. It is useful for primary care clinicians to be able to recognise which drugs are CPIs, because it may help to explain the cause of a patient’s presenting symptoms. 

This issue also features a Differential diagnoses article on red eye. Red eye is a common presentation in general practice and the causes are many and varied. Dr Neelima Sibal and Mr Ajai Tyagi use case studies to illustrate different reasons why a patient may present with red eye, including conjunctivitis, episcleritis, and angle-closure glaucoma. The authors discuss the different treatment and management strategies, highlight red flags for referral to ophthalmology, and describe the different eye examinations that should be part of a primary care consultation for a patient presenting with red eye.

Figure 3 Bacterial conjunctivitis

Red eye: what’s the diagnosis?

Dr Neelima Sibal and Mr Ajai Tyagi

Hopefully, one of the articles in this issue will prompt new learning or an opportunity for reflection. Reflection is an important part of the revalidation process for all healthcare professionals. Since the Bawa-Garba case earlier this year, some clinicians have become cautious about documenting their reflections. Updated guidance for doctors and medical students on being a reflective practitioner was published in September 2018, which provides practical advice to help clinicians make the most of reflective notes.

Dr Honor Merriman highlights the key messages from the updated guidance, including a number of reflection models and templates. One key take-home message is that a reflective note should focus on the learning that has taken place, rather than a factual report of what has happened, and any personal data should be anonymised.

Finally, this month’s View from the ground is an inspiring story by Dr Abbie Brooks about getting involved with her local parkrun, and the many benefits of taking part—for patients and practitioners alike.


Parkrun and being a GP

Dr Abbie Brooks

Looking ahead to next year, we are currently planning our features list for 2019. To make suggestions of topics you would like to see covered, please get in touch.