Understanding Eye Conditions Associated with Ankylosing Spondylitis

Ankylosing spondylitis (AS) is a chronic inflammatory disorder that primarily affects the sacroiliac joints and axial skeleton. However, it can also lead to various eye conditions. Uveitis, also known as iritis or iridocyclitis, is the most common extra-articular manifestation of AS, occurring in 20-30% of patients. Acute anterior uveitis is often unilateral and presents with symptoms such as a painful red eye, photophobia, and blurred vision. Patients with uveitis may also have or develop other spondyloarthropathies, including reactive arthritis, undifferentiated spondyloarthropathy, and psoriatic arthritis.

Acute angle-closure glaucoma, on the other hand, is not associated with AS. It is a medical emergency that needs immediate treatment to prevent vision loss. Conjunctivitis, which is responsible for approximately 30% of all eye complaints, is usually benign and self-limited. Herpes zoster ophthalmicus and keratoconus are also not associated with AS.

It is important for patients with AS to be aware of these potential eye conditions and seek urgent ophthalmological assessment if they experience any symptoms. Early diagnosis and treatment can prevent vision loss and improve outcomes.

Understanding Trigeminal Neuralgia

Trigeminal neuralgia is a type of pain syndrome that is characterized by severe pain on one side of the face. While most cases are idiopathic, some may be caused by compression of the trigeminal roots due to tumors or vascular problems. According to the International Headache Society, trigeminal neuralgia is defined as a disorder that causes brief electric shock-like pains that are limited to one or more divisions of the trigeminal nerve. The pain is often triggered by light touch, such as washing, shaving, or brushing teeth, and can occur spontaneously. Certain areas of the face, such as the nasolabial fold or chin, may be more susceptible to pain. The pain may also remit for varying periods.

Red flag symptoms and signs that suggest a serious underlying cause include sensory changes, ear problems, a history of skin or oral lesions that could spread perineurally, pain only in the ophthalmic division of the trigeminal nerve, optic neuritis, a family history of multiple sclerosis, and onset before the age of 40.

The first-line treatment for trigeminal neuralgia is carbamazepine. If there is a failure to respond to treatment or atypical features are present, such as onset before the age of 50, referral to neurology is recommended. Understanding the symptoms and management of trigeminal neuralgia is important for proper diagnosis and treatment.

If a patient has a Wells’ score of 1 or less for a suspected DVT, the first step is to arrange a D dimer test with results available within 4 hours, according to NICE guidelines. In this case, the score of 1 is due to localized tenderness along the deep venous system, with no other risk factors present. A proximal leg vein ultrasound scan is not the first-line investigation option for a Wells’ score of 1 or less, and anticoagulant treatment should not be started without a D dimer test. If the D dimer results cannot be obtained within 4 hours, low molecular weight heparin injection may be considered, but therapeutic dose apixaban should not be started without a D dimer test.

NICE updated their guidelines on the investigation and management of venous thromboembolism (VTE) in 2020. The use of direct oral anticoagulants (DOACs) is recommended as first-line treatment for most people with VTE, including as interim anticoagulants before a definite diagnosis is made. Routine cancer screening is no longer recommended following a VTE diagnosis. The cornerstone of VTE management is anticoagulant therapy, with DOACs being the preferred choice. All patients should have anticoagulation for at least 3 months, with the length of anticoagulation being determined by whether the VTE was provoked or unprovoked.

Risks of Smoking, Alcohol, and Illegal Drugs During Pregnancy

During pregnancy, drug use can have serious consequences for both the mother and the developing fetus. Smoking during pregnancy increases the risk of miscarriage, pre-term labor, stillbirth, and sudden unexpected death in infancy. Alcohol consumption can lead to fetal alcohol syndrome, which can cause learning difficulties, characteristic facial features, and growth restrictions. Binge drinking is a major risk factor for fetal alcohol syndrome. Cannabis use poses similar risks to smoking due to the tobacco content. Cocaine use can lead to hypertension in pregnancy, including pre-eclampsia, and placental abruption. Fetal risks include prematurity and neonatal abstinence syndrome. Heroin use can result in neonatal abstinence syndrome. It is important for pregnant women to avoid drug use to ensure the health and well-being of both themselves and their unborn child.

Distinguishing between Acute Kidney Injury and Chronic Kidney Disease

One of the most effective ways to differentiate between acute kidney injury (AKI) and chronic kidney disease (CKD) is through the use of renal ultrasound. In most cases, patients with CKD will have small kidneys that are bilateral. However, there are some exceptions to this rule, including individuals with autosomal dominant polycystic kidney disease, diabetic nephropathy in its early stages, amyloidosis, and HIV-associated nephropathy.

In addition to renal ultrasound, there are other features that can suggest CKD rather than AKI. For example, individuals with CKD may experience hypocalcaemia due to a lack of vitamin D. By identifying these distinguishing factors, healthcare professionals can more accurately diagnose and treat patients with kidney disease. Proper diagnosis is crucial, as the treatment and management of AKI and CKD differ significantly.

Implanon and Nexplanon are subdermal contraceptive implants that slowly release the progestogen hormone etonogestrel to prevent ovulation and thicken cervical mucus. Nexplanon is the newer version and has a redesigned applicator to prevent deep insertions and is radiopaque for easier location. It is highly effective with a failure rate of 0.07/100 women-years and lasts for 3 years. It does not contain estrogen, making it suitable for women with a past history of thromboembolism or migraine. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraceptive methods are required for the first 7 days if not inserted on days 1 to 5 of a woman’s menstrual cycle.

The main disadvantage of these implants is irregular and heavy bleeding, which can be managed with a co-prescription of the combined oral contraceptive pill. Other adverse effects include headache, nausea, and breast pain. Enzyme-inducing drugs such as certain antiepileptic and rifampicin may reduce the efficacy of Nexplanon, and women should switch to a method unaffected by enzyme-inducing drugs or use additional contraception until 28 days after stopping the treatment.

There are also contraindications for using these implants, such as ischaemic heart disease/stroke, unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Current breast cancer is a UKMEC 4 condition, which represents an unacceptable risk if the contraceptive method is used. Overall, these implants are a highly effective and long-acting form of contraception, but they require careful consideration of the potential risks and contraindications.

Understanding Kawasaki Disease: Diagnosis and Blood Test Results

Kawasaki disease is a clinical diagnosis that presents with a persistent fever and at least four of the following five criteria: bilateral conjunctival injection, polymorphous rash, oral changes, oedema and erythema in hands/feet, and cervical lymphadenopathy. Thrombocytosis is a common non-specific change seen in Kawasaki disease, and blood tests such as full blood count, urea and electrolytes, liver function, lipid profile, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) can support the diagnosis, assess severity, and monitor disease and treatment. Neutropenia is not usually associated with Kawasaki disease, and a raised white cell count with a relative neutrophilia is commonly seen. An elevated CRP with a normal ESR or an elevated ESR with a normal CRP would not be expected in Kawasaki disease, as both markers reflect acute inflammation. Kawasaki disease is associated with normocytic anaemia, but not macrocytic anaemia. It is important to arrange an echocardiogram as soon as possible to look for any initial evidence of coronary artery aneurysm, a common complication of Kawasaki disease.

To evaluate diabetic neuropathy in the feet, it is recommended to utilize a monofilament weighing 10 grams.

Diabetic foot disease is a significant complication of diabetes mellitus that requires regular screening. In 2015, NICE published guidelines on diabetic foot disease. The disease is caused by two main factors: neuropathy, which results in a loss of protective sensation, and peripheral arterial disease, which increases the risk of macro and microvascular ischaemia. Symptoms of diabetic foot disease include loss of sensation, absent foot pulses, reduced ankle-brachial pressure index (ABPI), intermittent claudication, calluses, ulceration, Charcot’s arthropathy, cellulitis, osteomyelitis, and gangrene. All patients with diabetes should be screened for diabetic foot disease at least once a year. Screening for ischaemia involves palpating for both the dorsalis pedis pulse and posterial tibial artery pulse, while screening for neuropathy involves using a 10 g monofilament on various parts of the sole of the foot. NICE recommends that patients be risk-stratified into low, moderate, and high-risk categories based on factors such as deformity, previous ulceration or amputation, renal replacement therapy, neuropathy, and non-critical limb ischaemia. Patients who are moderate or high-risk should be regularly followed up by their local diabetic foot centre.

The impairment of external rotation, both on active and passive movement, is a classic feature of adhesive capsulitis. This condition is the most likely diagnosis, as the patient’s symptoms of restricted active and passive external rotation have only been present for the last 4 weeks. Osteoarthritis, on the other hand, tends to present with a more chronic pain history. Adhesive capsulitis is often associated with endocrine conditions such as diabetes and thyroid disease, and has three distinct phases: painful, stiff, and recovery. Physiotherapy is the mainstay of treatment, but early intra-articular steroid injection may be considered if conservative measures are not effective. Biceps tendonitis typically presents with anterior shoulder pain and point tenderness over the biceps tendon on examination. Inflammatory arthritis is unlikely as there are no other joint involvements, morning stiffness, or systemic symptoms, and the history and examination are consistent with adhesive capsulitis. While osteoarthritis may be considered in the differential diagnosis, the duration of symptoms and classic examination findings suggest adhesive capsulitis as the most likely diagnosis.

Understanding Adhesive Capsulitis (Frozen Shoulder)

Adhesive capsulitis, commonly known as frozen shoulder, is a prevalent cause of shoulder pain that primarily affects middle-aged women. The exact cause of this condition is not yet fully understood. However, studies have shown that up to 20% of diabetics may experience an episode of frozen shoulder. Symptoms typically develop over several days, with external rotation being more affected than internal rotation or abduction. Both active and passive movement are affected, and patients usually experience a painful freezing phase, an adhesive phase, and a recovery phase. In some cases, the condition may affect both shoulders, which occurs in up to 20% of patients. The episode typically lasts between 6 months and 2 years.

Diagnosis of adhesive capsulitis is usually clinical, although imaging may be necessary for atypical or persistent symptoms. Unfortunately, no single intervention has been proven to improve the outcome in the long-term. However, there are several treatment options available, including nonsteroidal anti-inflammatory drugs (NSAIDs), physiotherapy, oral corticosteroids, and intra-articular corticosteroids.

Understanding Visual Field Defects: A Guide to Lesion Locations and Symptoms

Visual field defects can provide important clues about the location and nature of neurological lesions. Here is a breakdown of the different types of visual field defects and their associated lesion locations:

– Retina/optic disc: Scotoma
– Optic nerve: Unilateral blindness (ipsilateral) or scotoma
– Lateral optic chiasm: Incomplete/contralateral hemianopia
– Central optic chiasm: Bitemporal hemianopia
– Optic tract: Contralateral homonymous hemianopia (incongruent)
– Temporal lobe/optic radiation: Contralateral superior quadrantanopia
– Parietal lobe/superior optic radiation: Contralateral inferior quadrantanopia
– Complete parieto-occipital interruption of optic radiation: Contralateral congruent homonymous hemianopia (may be macula sparing)

It is important to note that incomplete lesions may produce asymmetrical/incongruent homonymous hemianopia, while complete lesions result in congruous homonymous hemianopia, relative afferent pupillary defect (RAPD), and optic nerve atrophy. Other symptoms may also be present depending on the lesion location, such as language defects, neglect, and movement or color agnosia. By understanding the different visual field defects and their associated lesion locations, healthcare professionals can better diagnose and treat neurological conditions.