Haemodialysis Access Options

Haemodialysis access is the formation of a permanent connection between an artery and a vein to allow for efficient dialysis treatment. The ideal location for this connection is in the arm, where the radial artery is joined to the cephalic vein on the non-dominant arm. If this is not possible, a brachial artery-cephalic vein connection is formed higher up the arm. Leg fistulas are used as a last resort due to complications such as infection and positional access.

In cases where a direct arteriovenous connection is not possible, a PTFE graft is used. However, this foreign material has a higher risk of infection. A tunnelled internal jugular dialysis catheter is a good option for urgent access, but it is not as efficient as fistulas in clearing waste products due to recirculation of blood.

Tenckhoff catheters are used for peritoneal dialysis. It is important to consider the pros and cons of each option when choosing the best haemodialysis access for a patient. Fistulas are the preferred option, but in some cases, other options may be necessary.

The Role of Kidney Function in Anaemia of ESRD Patients

Erythropoietin (EPO) is synthesized and secreted by the kidney, making it a crucial factor in maintaining haematopoiesis. Patients with end-stage renal disease (ESRD) often suffer from severe anaemia and require exogenous EPO to address this issue. A hypoproliferative disorder, ESRD may or may not be accompanied by anaemia of chronic disease or iron deficiency, leading to decreased reticulocytes. Iron supplementation is often necessary in conjunction with EPO to maintain haematopoiesis in dialysis patients.

Renin, on the other hand, is not implicated in anaemia. Aldosterone, which is part of the renin-angiotensin pathway that originates in the kidney, is not directly involved in anaemia either. Any derangement in aldosterone levels secondary to ESRD would have been normalized by now in the kidney.

Normalizing kidney function may improve the iron levels of the patient, but the primary effect of renal disease is insufficient EPO secretion, leading to anaemia. Patients with ESRD are typically phosphate-overloaded and calcium-deficient. While a transplant may lead to decreased phosphate levels due to increased clearance, this is not directly implicated in haematopoiesis.

Common Nerve Injuries Associated with Mid-Humeral Shaft Fractures

Mid-humeral shaft fractures can result in nerve damage, leading to various symptoms. Here are some common nerve injuries associated with this type of fracture:

1. Loss of sensation to the dorsum of the right hand: This is likely due to damage to the radial nerve, which provides sensation to the dorsum of the hand and innervates the extensor compartment of the forearm.

2. Atrophy of the deltoid muscle: This may occur in shoulder dislocation or compression of the axilla, leading to weakness of adduction and loss of sensation over a small patch of the lateral upper arm.

3. Inability to flex the wrist: This is controlled by the median nerve, which is more likely to be damaged in a supracondylar fracture.

4. Loss of sensation to the right fifth finger: This is innervated by the ulnar nerve, which can be compressed at the medial epicondyle of the humerus, causing ulnar entrapment.

While compartment syndrome can also occur with mid-humeral shaft fractures, it is unlikely if no major bleeding was observed. It is important to be aware of these potential nerve injuries and seek medical attention if any symptoms arise.

If a patient has an ectopic pregnancy, the treatment plan will depend on various factors such as the size and location of the pregnancy, the patient’s overall health, and the potential impact on their fertility. If the pregnancy is small and the patient’s health is stable, they may be able to receive medication to dissolve the pregnancy. However, if the pregnancy is larger or causing severe symptoms, surgery may be necessary.

In cases where surgery is required, the surgeon may attempt to preserve the affected fallopian tube if possible. However, if the tube is severely damaged or the patient has other factors that may affect their fertility, such as age or previous fertility issues, the surgeon may opt to remove the tube completely. This decision will also depend on the patient’s desire for future fertility and the likelihood of requiring further treatment with methotrexate or a salpingectomy. If the patient’s contralateral tube is unaffected, complete removal of the affected tube may be the most appropriate course of action.

Ectopic pregnancy is a serious condition that requires prompt investigation and management. Women who are stable are typically investigated and managed in an early pregnancy assessment unit, while those who are unstable should be referred to the emergency department. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound, which will confirm the presence of a positive pregnancy test.

There are three ways to manage ectopic pregnancies: expectant management, medical management, and surgical management. The choice of management will depend on various criteria, such as the size of the ectopic pregnancy, whether it is ruptured or not, and the patient’s symptoms and hCG levels. Expectant management involves closely monitoring the patient over 48 hours, while medical management involves giving the patient methotrexate and requires follow-up. Surgical management can involve salpingectomy or salpingostomy, depending on the patient’s risk factors for infertility.

Salpingectomy is the first-line treatment for women without other risk factors for infertility, while salpingostomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingostomy require further treatment, such as methotrexate and/or a salpingectomy. It is important to carefully consider the patient’s individual circumstances and make a decision that will provide the best possible outcome.

Compression stockings are the recommended treatment for superficial thrombophlebitis. This is because they are effective in managing symptoms and aiding in the resolution of the condition. The patient’s history of varicose veins, along with examination and investigation results, strongly support the diagnosis of superficial thrombophlebitis. The ankle-brachial pressure index was checked to ensure that the arterial supply is sufficient, as compression stockings may compromise this. In addition to compression stockings, a low-molecular-weight heparin or fondaparinux may also be used. Intravenous antibiotics are not necessary in this case, as there is no evidence of severe infection. Rivaroxaban and warfarin are not typically used in the management of superficial thrombophlebitis, as there is no evidence of deep vein thrombosis. While some vascular surgeons may prescribe topical heparinoid, there is little evidence supporting its use in treating this condition, and it is not part of the main guidelines for management.

Superficial thrombophlebitis is inflammation associated with thrombosis of a superficial vein, usually the long saphenous vein of the leg. Around 20% of cases have an underlying deep vein thrombosis (DVT) and 3-4% may progress to a DVT if untreated. Treatment options include NSAIDs, topical heparinoids, compression stockings, and low-molecular weight heparin. Patients with clinical signs of superficial thrombophlebitis affecting the proximal long saphenous vein should have an ultrasound scan to exclude concurrent DVT. Patients with superficial thrombophlebitis at, or extending towards, the saphenofemoral junction can be considered for therapeutic anticoagulation for 6-12 weeks.

Treatment Options for Bacterial Conjunctivitis in Pregnant Women

Bacterial conjunctivitis is a common eye infection that can occur during pregnancy. While topical antibiotics are the mainstay of treatment, certain options should be avoided or used with caution in pregnant women. Here are the treatment options for bacterial conjunctivitis in pregnant women:

Topical Fusidic Acid Eye Drops: These eye drops are typically a second-line choice for treating bacterial conjunctivitis, but they are often the first-line treatment for pregnant women.

Topical Steroid Eye Drops: These eye drops are not recommended for bacterial conjunctivitis, especially in pregnant women.

Artificial Tears: While artificial tears can provide relief for dry eyes, they are not useful in treating bacterial conjunctivitis.

Eye Shield: An eye shield is not necessary for bacterial conjunctivitis.

Topical Chloramphenicol Eye Drops: Topical antibiotics are effective in treating bacterial conjunctivitis, but chloramphenicol should be avoided in pregnant women unless it is essential. The British National Formulary recommends avoiding topical chloramphenicol due to the risk of neonatal grey-baby syndrome with oral use in the third trimester.

Appropriate Management of Suspected Gastro-Oesophageal Malignancy

Suspected gastro-oesophageal malignancy requires urgent referral, according to NICE guidelines. A patient’s age, weight loss, and dyspepsia symptoms meet the criteria for referral. An ultrasound of the abdomen may be useful to rule out biliary disease, but it would not be helpful in assessing oesophageal or stomach pathology. Treatment with proton pump inhibitors may mask malignancy signs and delay diagnosis. Helicobacter testing can be useful for dyspepsia patients, but red flag symptoms require urgent malignancy ruling out. A barium swallow is not a gold-standard test for gastro-oesophageal malignancy.

To manage premenstrual syndrome, it is recommended to make specific lifestyle changes such as regular exercise and consuming small, balanced meals rich in complex carbohydrates every 2-3 hours. These changes are advised by the Royal College of Obstetrics and Gynaecology as a first-line management approach. It is also suggested to quit smoking, reduce alcohol intake, maintain regular sleep patterns, and manage stress levels. Contrary to popular belief, reducing dietary fats and carbohydrates is not recommended. Additionally, prescribing diazepam is not a routine management approach and is only used in select cases where anxiety is a significant symptom. Selective serotonin reuptake inhibitors like sertraline can be used for severe premenstrual syndrome, but lifestyle changes are usually sufficient for mild symptoms that do not interfere with daily life.

Understanding Premenstrual Syndrome (PMS)

Premenstrual syndrome (PMS) is a condition that affects women during the luteal phase of their menstrual cycle. It is characterized by emotional and physical symptoms that can range from mild to severe. PMS only occurs in women who have ovulatory menstrual cycles and does not occur before puberty, during pregnancy, or after menopause.

Emotional symptoms of PMS include anxiety, stress, fatigue, and mood swings. Physical symptoms may include bloating and breast pain. The severity of symptoms varies from woman to woman, and management options depend on the severity of symptoms.

Mild symptoms can be managed with lifestyle advice, such as getting enough sleep, exercising regularly, and avoiding smoking and alcohol. Specific advice includes eating regular, frequent, small, balanced meals that are rich in complex carbohydrates.

Moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP), such as Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg). Severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI), which can be taken continuously or just during the luteal phase of the menstrual cycle (for example, days 15-28, depending on the length of the cycle). Understanding PMS and its management options can help women better cope with this common condition.

IV acetazolamide is the appropriate initial emergency medical treatment for acute angle-closure glaucoma, in addition to eye drops. This diagnosis is suggested by the patient’s symptoms of severe headache, visual disturbance, and vomiting, as well as the presence of mydriasis and hypermetropia. Oral amitriptyline and oxybutynin should not be used in the management of acute angle-closure glaucoma as they can worsen the condition. Topical dorzolamide is typically used for primary open-angle glaucoma.

Glaucoma is a group of disorders that cause optic neuropathy due to increased intraocular pressure (IOP). However, not all patients with raised IOP have glaucoma, and vice versa. Acute angle-closure glaucoma (AACG) is a type of glaucoma where there is a rise in IOP due to impaired aqueous outflow. Factors that increase the risk of AACG include hypermetropia, pupillary dilation, and lens growth associated with age. Symptoms of AACG include severe pain, decreased visual acuity, halos around lights, and a hard, red-eye. Management of AACG is an emergency and requires urgent referral to an ophthalmologist. Emergency medical treatment is necessary to lower the IOP, followed by definitive surgical treatment once the acute attack has subsided.

There are no specific guidelines for the initial medical treatment of AACG, but a combination of eye drops may be used, including a direct parasympathomimetic, a beta-blocker, and an alpha-2 agonist. Intravenous acetazolamide may also be administered to reduce aqueous secretions. Definitive management of AACG involves laser peripheral iridotomy, which creates a small hole in the peripheral iris to allow aqueous humour to flow to the angle. It is important to seek medical attention immediately if symptoms of AACG are present to prevent permanent vision loss.

Nimodipine is used to prevent vasospasm in aneurysmal subarachnoid haemorrhages. It is recommended by NICE guidelines for blood pressure control in SAH patients. Dexamethasone is not routinely given in SAH cases. Labetalol and nifedipine are not appropriate for this patient as they are not hypertensive.

A subarachnoid haemorrhage (SAH) is a type of bleeding that occurs within the subarachnoid space of the meninges in the brain. It can be caused by head injury or occur spontaneously. Spontaneous SAH is often caused by an intracranial aneurysm, which accounts for around 85% of cases. Other causes include arteriovenous malformation, pituitary apoplexy, and mycotic aneurysms. The classic symptoms of SAH include a sudden and severe headache, nausea and vomiting, meningism, coma, seizures, and ECG changes.

The first-line investigation for SAH is a non-contrast CT head, which can detect acute blood in the basal cisterns, sulci, and ventricular system. If the CT is normal within 6 hours of symptom onset, a lumbar puncture is not recommended. However, if the CT is normal after 6 hours, a lumbar puncture should be performed at least 12 hours after symptom onset to check for xanthochromia and other CSF findings consistent with SAH. If SAH is confirmed, referral to neurosurgery is necessary to identify the underlying cause and provide urgent treatment.

Management of aneurysmal SAH involves supportive care, such as bed rest, analgesia, and venous thromboembolism prophylaxis. Vasospasm is prevented with oral nimodipine, and intracranial aneurysms require prompt intervention to prevent rebleeding. Most aneurysms are treated with a coil by interventional neuroradiologists, but some require a craniotomy and clipping by a neurosurgeon. Complications of aneurysmal SAH include re-bleeding, hydrocephalus, vasospasm, and hyponatraemia. Predictive factors for SAH include conscious level on admission, age, and amount of blood visible on CT head.