The use of diclofenac is now prohibited for individuals with any type of cardiovascular ailment.

MHRA Guidance on Diclofenac and Cardiovascular Safety

The MHRA has updated its guidance on diclofenac, a nonsteroidal anti-inflammatory drug (NSAID), after a Europe-wide review of cardiovascular safety. While it has been known for some time that NSAIDs may increase the risk of cardiovascular events, the evidence base has become clearer. Diclofenac is associated with a significantly higher risk of cardiovascular events compared to other NSAIDs. Therefore, it is contraindicated in patients with ischaemic heart disease, peripheral arterial disease, cerebrovascular disease, and congestive heart failure (New York Heart Association classification II-IV). Patients should switch from diclofenac to other NSAIDs such as naproxen or ibuprofen, except for topical diclofenac. Studies have shown that naproxen and low-dose ibuprofen have the best cardiovascular risk profiles of the NSAIDs.

The MHRA’s updated guidance on diclofenac and cardiovascular safety highlights the increased risk of cardiovascular events associated with this NSAID compared to other NSAIDs. Patients with certain conditions are advised to avoid diclofenac and switch to other NSAIDs. This guidance is important for healthcare professionals to consider when prescribing NSAIDs to patients with cardiovascular risk factors.

Chlamydia is a common sexually transmitted infection caused by Chlamydia trachomatis. It is prevalent in the UK, with approximately 1 in 10 young women affected. The incubation period is around 7-21 days, but many cases are asymptomatic. Symptoms in women include cervicitis, discharge, and bleeding, while men may experience urethral discharge and dysuria. Complications can include epididymitis, pelvic inflammatory disease, and infertility.

Traditional cell culture is no longer widely used for diagnosis, with nuclear acid amplification tests (NAATs) being the preferred method. Testing can be done using urine, vulvovaginal swab, or cervical swab. Screening is recommended for sexually active individuals aged 15-24 years, and opportunistic testing is common.

Doxycycline is the first-line treatment for Chlamydia, with azithromycin as an alternative if doxycycline is contraindicated or not tolerated. Pregnant women may be treated with azithromycin, erythromycin, or amoxicillin. Patients diagnosed with Chlamydia should be offered partner notification services, with all contacts since the onset of symptoms or within the last six months being notified and offered treatment.

Treatment Options for Helicobacter pylori Infection

Helicobacter pylori is a common bacterial infection that can cause dyspepsia and gastro-oesophageal reflux disease (GORD). There are several treatment options available for patients who test positive for H. pylori.

One option is a 7-day course of a proton pump inhibitor (PPI), amoxicillin, and either clarithromycin or metronidazole. This should be followed by a PPI for 4-8 weeks. Patients who are allergic to penicillin and have had previous exposure to clarithromycin should be offered a 7-day course of a PPI, bismuth, metronidazole, and tetracycline.

Long-term PPI and dietary advice alone will not eradicate H. pylori. If symptoms return after initial care strategies for dyspepsia, step down PPI therapy to the lowest dose needed to control symptoms. Patients with GORD should be offered full-dose PPI.

It is important to consult the British National Formulary (BNF) for appropriate doses of each drug, as they may vary. Sucralfate has no role in the eradication of H. pylori.

Understanding the Signs and Symptoms of Frontotemporal Dementia and Lewy Body Dementia

Frontotemporal dementia (FTD) and Lewy body dementia (LBD) are two types of dementia that can cause a range of symptoms. Understanding the signs and symptoms of these conditions can help with early diagnosis and treatment.

Fluctuating confusion and hallucination are common signs of LBD, which is caused by protein deposits in nerve cells in the brain. People with LBD may also experience Parkinson’s disease symptoms such as rigid muscles and tremors. On the other hand, FTD is characterized by an insidious onset and a gradual progression. Personality changes, social-conduct problems, and a decline in judgment and empathy are common features of FTD.

While memory loss is a more prominent symptom in early Alzheimer’s, it can also occur in advanced stages of FTD and LBD. However, relatively preserved memory is more characteristic of FTD in its early stages. Additionally, FTD tends to have an onset before age 65, with some cases diagnosed in individuals as young as 17 years old.

Overall, recognizing the signs and symptoms of FTD and LBD can help with early diagnosis and management of these conditions.

The primary management approach for NAFLD is weight loss, achieved through diet and exercise. Medications have not shown to be effective in improving the condition’s outcome.

Non-Alcoholic Fatty Liver Disease: Causes, Features, and Management

Non-alcoholic fatty liver disease (NAFLD) is a prevalent liver disease in developed countries, primarily caused by obesity. It encompasses a range of conditions, from simple steatosis (fat accumulation in the liver) to steatohepatitis (fat with inflammation) and may progress to fibrosis and liver cirrhosis. Insulin resistance is believed to be the primary mechanism leading to steatosis, making NAFLD a hepatic manifestation of metabolic syndrome. Non-alcoholic steatohepatitis (NASH) is a type of liver damage similar to alcoholic hepatitis but occurs in the absence of alcohol abuse. It affects around 3-4% of the general population and may be responsible for some cases of cryptogenic cirrhosis.

NAFLD is usually asymptomatic, but hepatomegaly, increased echogenicity on ultrasound, and elevated ALT levels are common features. The enhanced liver fibrosis (ELF) blood test is recommended by NICE to check for advanced fibrosis in patients with incidental NAFLD. If the ELF blood test is not available, non-invasive tests such as the FIB4 score or NAFLD fibrosis score, in combination with a FibroScan, may be used to assess the severity of fibrosis. Patients with advanced fibrosis should be referred to a liver specialist for further evaluation, which may include a liver biopsy to stage the disease more accurately.

The mainstay of NAFLD treatment is lifestyle changes, particularly weight loss, and monitoring. Research is ongoing into the role of gastric banding and insulin-sensitizing drugs such as metformin and pioglitazone. While there is no evidence to support screening for NAFLD in adults, NICE guidelines recommend the management of incidental NAFLD findings.

Differential Diagnosis: Polyuria, Polydipsia, Constipation, and Loin-to-Groin Pain

Possible Causes and Clinical Features

Primary Hyperparathyroidism: This condition can cause hypercalcemia, leading to symptoms such as bone pain, osteopenia, kidney stones, constipation, nausea, vomiting, abdominal pain, fatigue, depression, and memory impairment. In severe cases, cardiac and metabolic disturbances, delirium, or coma may occur. Diagnosis is made by measuring serum-adjusted calcium and parathyroid hormone (PTH) levels at the same time.

Acute Pancreatitis: This condition can cause severe epigastric pain radiating to the back, vomiting, epigastric tenderness, ileus, and low-grade fever. Aetiological factors include alcohol and gallstones.

Addison’s Disease: This condition can cause generalised fatigue, abdominal pain, anorexia, nausea, vomiting, weight loss, ‘salt craving’, hyperpigmentation, vitiligo, loss of pubic hair in women, hypotension, hypoglycaemia, hyponatraemia, and hyperkalaemia.

Anxiety Attack: This condition can cause chest pain, palpitations, nausea, vomiting, sweating, insomnia, flushing, tremor, and urinary frequency. It typically occurs in an individual who is excessively worried about a number of different events, causing increased tension.

Diabetic Ketoacidosis (DKA): This condition can cause polyuria, polydipsia, abdominal pain, Kussmaul respiration, and pear-drops-smelling breath.

Differential Diagnosis of Polyuria, Polydipsia, Constipation, and Loin-to-Groin Pain

Seborrhoeic dermatitis is the likely diagnosis for this man’s rash, especially given his medical history of HIV. The recommended first-line treatment for this condition is topical ketoconazole. While oral fluconazole may be useful for treating fungal infections and preventing them in HIV patients, it is not effective for seborrhoeic dermatitis. Oral prednisolone is only used for short periods to treat severe inflammatory skin diseases like atopic dermatitis and is not indicated for seborrhoeic dermatitis. Although topical steroids like hydrocortisone can be used to treat seborrhoeic dermatitis, they are not the preferred initial treatment.

Understanding Seborrhoeic Dermatitis in Adults

Seborrhoeic dermatitis is a chronic skin condition that affects around 2% of the general population. It is caused by an inflammatory reaction related to the overgrowth of a fungus called Malassezia furfur, which is a normal inhabitant of the skin. The condition is characterized by eczematous lesions that appear on the sebum-rich areas of the body, such as the scalp, periorbital, auricular, and nasolabial folds. It can also lead to the development of otitis externa and blepharitis.

Seborrhoeic dermatitis is often associated with other medical conditions, such as HIV and Parkinson’s disease. The management of the condition depends on the affected area. For scalp disease, over-the-counter preparations containing zinc pyrithione and tar are usually the first-line treatment. If these are not effective, ketoconazole is the preferred second-line agent. Selenium sulphide and topical corticosteroids may also be useful.

For the face and body, topical antifungals such as ketoconazole and topical steroids are often used. However, it is important to use steroids for short periods only to avoid side effects. Seborrhoeic dermatitis can be difficult to treat, and recurrences are common. Therefore, it is important to work closely with a healthcare provider to manage the condition effectively.

Treatment Options for Deep Vein Thrombosis in Pregnancy

Start subcutaneous low molecular weight heparin (LMWH) throughout pregnancy and change to warfarin in the postpartum period: LMWH is recommended for the treatment of DVT during pregnancy. Treatment should be continued for at least three months and until six weeks postpartum. Warfarin can be used after day five of the postpartum period. Both LMWH and warfarin are safe to use while breastfeeding.

Elastic band compression of the affected leg, bedrest, and foot elevation: These measures have no benefit in treating DVT and may even increase the risk of developing a pulmonary embolism (PE) or another DVT.

Commence intravenous (IV) heparin: IV heparin can be used for the treatment of a shocked patient with PE if thrombolysis is not possible. It should not be used for DVT alone.

Oral anticoagulation with warfarin daily throughout pregnancy and the postpartum period: Warfarin is not recommended during pregnancy as it can cross the placenta and increase the risk of congenital malformations and bleeding.

Aspirin 300 mg daily throughout pregnancy and the postpartum period: Aspirin is not effective in treating DVT or PE as it is an antiplatelet drug, not an anticoagulant.

Treatment Options for Deep Vein Thrombosis in Pregnancy

Barrett’s oesophagus is most strongly associated with the presence of GORD as a risk factor.

Understanding Barrett’s Oesophagus

Barrett’s oesophagus is a condition where the lower oesophageal mucosa is replaced by columnar epithelium, increasing the risk of oesophageal adenocarcinoma by 50-100 fold. It is typically identified during an endoscopy for upper gastrointestinal symptoms such as dyspepsia. The length of the affected segment correlates strongly with the chances of identifying metaplasia, with the overall prevalence estimated to be around 1 in 20. Risk factors include gastro-oesophageal reflux disease (GORD), male gender, smoking, and central obesity. Interestingly, alcohol does not seem to be an independent risk factor for Barrett’s. Management includes high-dose proton pump inhibitors and endoscopic surveillance with biopsies every 3-5 years for patients with metaplasia. If dysplasia of any grade is identified, endoscopic intervention such as radiofrequency ablation or endoscopic mucosal resection is offered.

Barrett’s oesophagus is a condition where the lower oesophageal mucosa is replaced by columnar epithelium, increasing the risk of oesophageal adenocarcinoma. It is typically identified during an endoscopy for upper gastrointestinal symptoms such as dyspepsia. The length of the affected segment correlates strongly with the chances of identifying metaplasia, with the overall prevalence estimated to be around 1 in 20. Risk factors include GORD, male gender, smoking, and central obesity. Interestingly, alcohol does not seem to be an independent risk factor for Barrett’s. Management includes high-dose proton pump inhibitors and endoscopic surveillance with biopsies every 3-5 years for patients with metaplasia. If dysplasia of any grade is identified, endoscopic intervention such as radiofrequency ablation or endoscopic mucosal resection is offered.

Contraindications and Considerations for the Use of Donepezil

Donepezil is a medication used to treat Alzheimer’s disease. However, there are certain contraindications and considerations that healthcare professionals should keep in mind when prescribing this medication.

Bradycardia, a condition where the heart beats too slowly, is a relative contraindication for the use of donepezil. This medication may cause bradycardia and atrioventricular node block, so caution should be taken in patients with other cardiac abnormalities. Additionally, patients with asthma, chronic obstructive pulmonary disease, supraventricular conduction abnormalities, susceptibility to peptic ulcers, and sick-sinus syndrome should also be closely monitored when taking donepezil.

Concurrent use of simvastatin, a medication used to lower cholesterol levels, is not a concern when taking donepezil. General anxiety disorder (GAD) and diabetes mellitus type II are also not contraindications for the use of donepezil.

However, elderly patients with a known history of persistent bradycardia, heart block, recurrent unexplained syncope, or concurrent treatment with drugs that reduce heart rate should avoid donepezil. A history of ischaemic heart diseases alone is not a contraindication for donepezil.

In summary, healthcare professionals should carefully consider a patient’s medical history and current medications before prescribing donepezil. Close monitoring is necessary in patients with certain cardiac abnormalities and caution should be taken in elderly patients with a history of bradycardia or heart block.