Local Medical Committees: Representing the Interests of GPs

Local Medical Committees (LMCs) were established in 1911 as part of Lloyd George’s National Insurance Act to ensure that GPs had a say in the government’s health insurance scheme. LMCs represent the interests of GPs on a local level, while a committee within the British Medical Association (BMA) represents GPs on a national level to the government. This committee, now called the General Practitioners Committee (GPC), has the authority to negotiate with the government on matters such as pay and contracts and is recognised by the Department of Health as the GP’s sole negotiating body.

LMCs are funded by a statutory levy on GPs and may cover the area which corresponds to one or more Clinical Commissioning Groups. LMC members are elected and include partners, salaried doctors, and GP Registrars from both GMS and PMS practices. The GPC meets annually with the representatives of the LMCs, who may submit motions for the conference. These motions may then go on to form GPC policy.

Overall, LMCs play an important role in representing the interests of GPs on a local level and ensuring that their voices are heard in the government’s decision-making processes.

Raloxifene: A Selective Oestrogen Receptor Modulator

Raloxifene is a medication that belongs to the class of selective oestrogen receptor modulators (SERMs). It works by selectively binding to oestrogen receptors in different parts of the body, acting as an agonist or antagonist depending on the location.

There are two types of oestrogen receptors, alpha and beta, which are found in various locations such as the breast, uterus, bone, and vasculature. Raloxifene acts as an oestrogen agonist in the bone, promoting mineralisation, while acting as an antagonist in the uterus and breast, preventing hyperplasia.

This is different from tamoxifen, another SERM, which acts as a partial agonist in the endometrium and can promote endometrial hyperplasia. Raloxifene’s selective action makes it a useful medication for treating osteoporosis and reducing the risk of breast cancer in postmenopausal women.

Vertigo is most commonly caused by BPPV.

Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo that occurs suddenly when there is a change in head position. It is more prevalent in individuals over the age of 55 and is less common in younger patients. Symptoms of BPPV include dizziness and vertigo, which can be accompanied by nausea. Each episode typically lasts for 10-20 seconds and can be triggered by rolling over in bed or looking upwards. A positive Dix-Hallpike manoeuvre, which is indicated by vertigo and rotatory nystagmus, can confirm the diagnosis of BPPV.

Fortunately, BPPV has a good prognosis and usually resolves on its own within a few weeks to months. Treatment options include the Epley manoeuvre, which is successful in around 80% of cases, and vestibular rehabilitation exercises such as the Brandt-Daroff exercises. While medication such as Betahistine may be prescribed, it tends to have limited effectiveness. However, it is important to note that around half of individuals with BPPV may experience a recurrence of symptoms 3-5 years after their initial diagnosis.

Referral Guidelines for Sudden or Rapidly Worsening Hearing Loss in Adults

Adults who experience sudden onset or rapidly worsening hearing loss in one or both ears, which cannot be explained by external or middle ear causes, require referral to an ENT or audiovestibular medicine service. The speed at which this referral needs to occur is outlined in NICE guidance. If the loss occurred suddenly within the past 30 days, immediate referral to be seen within 24 hours is necessary. For sudden hearing loss that occurred more than 30 days ago, urgent referral to be seen within 2 weeks is appropriate. Rapid hearing loss over a period of 4 to 90 days also requires urgent referral. It is important to follow these guidelines to ensure prompt evaluation and appropriate management of hearing loss in adults.

Unilateral Wheeze and Poor Asthma Control

All the symptoms of asthma are present, but a peak flow of less than 300 indicates poor control. However, a unilateral wheeze may indicate a foreign body or tumor, especially in children. Therefore, further investigation is necessary to determine the cause of the wheeze.

In cases of recurrent vaginal candidiasis, it is important to consider a blood test to rule out diabetes as a potential underlying cause. This is because poorly controlled diabetes can increase the risk of Candida growth. While it is important to treat the symptoms of the infection, it is also crucial to investigate any predisposing factors that may be contributing to the recurrence.

Measuring TSH, free T3 and T4 levels to rule out hyperthyroidism is not necessary as there is no link between an overactive thyroid and Candida infections. Similarly, mid-stream urine to rule out UTI is not necessary unless the patient’s symptoms suggest a urinary tract infection. Referral to a specialist is also not necessary as recurrent vaginal candidiasis can be managed in primary care with an induction-maintenance regimen of antifungals. Specialist referral may only be necessary if the infective organism is resistant to treatment or if it is a non-albicans Candida species.

Vaginal candidiasis, commonly known as ‘thrush’, is a prevalent condition that many women self-diagnose and treat. Candida albicans is responsible for 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain conditions such as diabetes mellitus, drug use (antibiotics, steroids), pregnancy, and immunosuppression (HIV) may increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, dyspareunia, dysuria, itching, vulval erythema, fissuring, and satellite lesions.

Routine high vaginal swabs are not necessary if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy. The NICE Clinical Knowledge Summaries recommends oral fluconazole 150 mg as a single dose as the first-line treatment. If oral therapy is contraindicated, a single dose of clotrimazole 500 mg intravaginal pessary may be used. If vulval symptoms are present, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments such as cream or pessaries, as oral treatments are not recommended.

Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and the diagnosis of candidiasis should be confirmed. A high vaginal swab for microscopy and culture may be necessary, and a blood glucose test should be performed to exclude diabetes. Differential diagnoses such as lichen sclerosus should also be ruled out. An induction-maintenance regime may be used, consisting of oral fluconazole every three days for three doses as induction, followed by oral fluconazole weekly for six months as maintenance.

Fungal Nail Infection Treatment Options

Fungal nail infections are commonly caused by Trichophyton rubrum and Trichophyton mentagrophytes fungi. These two types of fungi are responsible for over 90% of cases, with T. rubrum being the most common culprit. Systemic treatment is recommended for fungal nail infections as it is more effective. However, the slow growth of nails means that they may not appear normal even after successful treatment.

Terbinafine is currently the first-line treatment for fungal nail infections, with evidence showing greater efficacy compared to itraconazole. However, itraconazole is more effective against candida. Treatment with terbinafine usually takes around 3 months to be effective. It is important to note that terbinafine is not licensed for use in children under 12 years old, in which case griseofulvin must be used.

There have been rare cases of liver toxicity with terbinafine, and very rare reports of severe skin reactions such as Stevens-Johnson syndrome and toxic epidermal necrolysis. Therefore, it is advisable to monitor hepatic function before treatment and every 4-6 weeks during treatment. If abnormalities in liver function tests occur, treatment should be discontinued.

Itraconazole can be given in pulses for 7 days every month to treat fungal nail infections. Two pulses are recommended for fingernails, and three for toenails.

In conclusion, fungal nail infections can be effectively treated with systemic antifungal medications such as terbinafine and itraconazole. However, it is important to monitor for potential side effects and to follow the recommended treatment regimen for optimal results.

Understanding Hepatitis B Test Results

Hepatitis B is a viral infection that affects the liver. Testing for hepatitis B involves checking for various antibodies and antigens in the blood. Here is a breakdown of what each result means:

Anti-HBs: This antibody indicates that a person has been vaccinated against hepatitis B.

Anti-HBsAb + anti-HBc: The presence of both antibodies suggests that a person has had a past infection with hepatitis B and is now immune.

Anti-HBeAb: This antibody indicates that a person is less infectious and is recovering from an acute infection.

HBsAg + HBcAg: The presence of both antigens suggests that a person is currently infected with hepatitis B.

Immunoglobulin M to HBcAg: The presence of this antibody indicates that a person has recently been infected with hepatitis B.

Understanding these test results can help healthcare providers diagnose and manage hepatitis B infections.

Dermatitis herpetiformis is a skin disease that causes blisters and is linked to coeliac disease. Both conditions are thought to be caused by autoantibodies that attack transglutaminase enzymes. DH is often seen in patients with coeliac disease, with around 80% of DH patients also showing signs of coeliac disease on small intestine biopsy. A rectal biopsy showing neutrophil infiltration would not be enough to diagnose coeliac disease, as a biopsy from the small intestine is needed to confirm the condition. Coeliac disease is a genetic disorder, and if one family member has it, there is a chance that their first-degree relatives may also be affected. Metronidazole would not help with coeliac disease symptoms, but may be used to treat other gastrointestinal conditions. Hydrogen breath testing is used to diagnose bacterial overgrowth and carbohydrate malabsorption, as bacteria in the intestine produce hydrogen during carbohydrate breakdown.

Henoch-Schönlein purpura is a common vasculitis that affects children and young adults, typically between the ages of 4 and 15. The condition is characterized by palpable purpura on dependent areas of the body, such as the lower limbs, and areas exposed to skin pressure. Other symptoms may include subcutaneous edema, joint pain, and gastrointestinal issues. Skin biopsy can reveal a leukocytoclastic vasculitis, and elevated levels of immunoglobulin A (IgA) are present in about half of patients. In some cases, Henoch-Schönlein purpura may follow a respiratory tract infection. Glomerulonephritis may also be present, which can be identified by microscopic hematuria, proteinuria, and red-cell casts. While renal involvement occurs in up to 40% of older children, it is serious in only about 10% of patients. Treatment may involve prednisolone for severe cases, with the addition of azathioprine if glomerulonephritis is present and associated with deteriorating renal function.

Understanding the Causes of Membranous Glomerulonephritis

Membranous glomerulonephritis is a kidney disease that often presents with a mixed nephrotic and nephritic picture. The condition is characterized by widespread thickening of the glomerular basement membrane, and its cause is often unknown. However, certain factors have been linked to the development of membranous glomerulonephritis, including cancers of the lung and bowel, infections such as hepatitis and malaria, and drugs like penicillamine and non-steroidal anti-inflammatory drugs.

One of the most significant risk factors for membranous glomerulonephritis is malignancy, which is responsible for approximately 5-10% of cases. Patients over the age of 60 are at higher risk, and effective treatment of the underlying malignancy can sometimes lead to improvement in renal symptoms. However, spontaneous recovery occurs in about one-third of patients, while one-third remain with membranous nephropathy and one-third progress to end-stage renal failure.

Other conditions, such as chronic obstructive pulmonary disease (COPD), hepatic fibrosis, hypercholesterolemia, and hypertension, can also impact renal function but do not directly cause membranous glomerulonephritis. COPD, for example, can induce microvascular damage, albuminuria, and a worsening of renal function, while hepatic fibrosis can lead to hepatorenal syndrome. Chronic hypertension can also lead to hardening of the arteries and a reduction in renal function. However, understanding the specific causes and risk factors for membranous glomerulonephritis is crucial for effective diagnosis and treatment.

Acute Limb Ischaemia: Urgent Treatment Required

Patients experiencing acute limb ischaemia require immediate medical attention to potentially save their limb. This condition is characterized by several features, including pain, pallor, pulselessness, paraesthesia, paralysis, and perishingly cold skin. Pain is always present, and the ankle pulses are always absent. A useful rule of thumb is that if you can count the pulse, it’s there, but if not, it probably isn’t. Paraesthesia and paralysis are late, limb-threatening signs that require urgent treatment. Therefore, patients with acute limb ischaemia should be admitted as an emergency to receive potentially limb-saving treatment.

Acute Pancreatitis: Causes and Risk Factors

Acute pancreatitis is a condition that can be caused by various factors. Certain drugs, such as azathioprine, can increase the risk of developing acute pancreatitis. Gallstones are also a common cause, and can be identified by the presence of Cullen’s sign (periumbilical darkening) or Gray-Turner’s sign (flank darkening). Infections like mumps and Coxsackie B can also lead to acute pancreatitis. Smoking and scorpion bites are other risk factors, with smoking having a synergistic effect when combined with high alcohol intake. Despite the various causes, most single acute episodes of pancreatitis result in uncomplicated recovery.

The forest plot and Kaplan-Meier curve in the report are not appropriate for the data presented. The forest plot is typically used in meta-analyses to display the weight and confidence intervals of individual studies and the overall results. The Kaplan-Meier curve is commonly used to show the data of a single survival analysis study. Instead, the report should include appropriate graphs or charts that clearly display the confidence intervals for the data.

Understanding Funnel Plots in Meta-Analyses

Funnel plots are graphical representations used to identify publication bias in meta-analyses. These plots typically display treatment effects on the horizontal axis and study size on the vertical axis. The shape of the funnel plot can provide insight into the presence of publication bias. A symmetrical, inverted funnel shape suggests that publication bias is unlikely. On the other hand, an asymmetrical funnel shape indicates a relationship between treatment effect and study size, which may be due to publication bias or systematic differences between smaller and larger studies (known as small study effects).

In summary, funnel plots are a useful tool for identifying potential publication bias in meta-analyses. By examining the shape of the plot, researchers can gain insight into the relationship between treatment effect and study size, and determine whether further investigation is necessary to ensure the validity of their findings.

The positive predictive value can be calculated by dividing the number of true positives by the sum of true positives and false positives. In this case, the positive predictive value is 19 out of 39, or approximately 0.487.

Precision refers to the consistency of a test in producing the same results when repeated multiple times. It is an important aspect of test reliability and can impact the accuracy of the results. In order to assess precision, multiple tests are performed on the same sample and the results are compared. A test with high precision will produce similar results each time it is performed, while a test with low precision will produce inconsistent results. It is important to consider precision when interpreting test results and making clinical decisions.

Testicular Lesions and Gynaecomastia in Young Males

This young male is presenting with tender gynaecomastia and a suspicious testicular lesion. The most likely diagnosis in this age group is a teratoma, as seminoma tends to be more common in older individuals. Gynaecomastia can be a presenting feature of testicular tumours, as the tumour may secrete betaHCG. Other tumour markers of teratoma include alphafetoprotein (AFP). It is important to note that testicular lymphoma typically presents in individuals over the age of 40 and is not associated with gynaecomastia. Early detection and treatment of testicular lesions is crucial for optimal outcomes.

Women who are taking antiepileptic medication and are planning to conceive should be prescribed folic acid 5mg instead of the standard 400 mcg once daily. This high dose of folic acid should be taken from before conception until 12 weeks into the pregnancy to reduce the risk of neural tube defects. It is important to refer these women to a specialist for assessment, but they should continue to use effective contraception until then. It is important to reassure these women that they are likely to have a normal pregnancy and healthy baby. Folic acid should be started as soon as possible, even if the pregnancy is unplanned.

Folic Acid: Importance, Deficiency, and Prevention

Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. THF plays a crucial role in transferring 1-carbon units to essential substrates involved in DNA and RNA synthesis. Green, leafy vegetables are a good source of folic acid. However, certain medications like phenytoin and methotrexate, pregnancy, and alcohol excess can cause folic acid deficiency. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.

To prevent neural tube defects during pregnancy, all women should take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if either partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with antiepileptic drugs or coeliac disease, diabetes, or thalassaemia trait, and those who are obese (BMI of 30 kg/m2 or more) are also at higher risk and should take the higher dose of folic acid.

When the data sets are not normally distributed, non-parametric tests are more suitable. This is evident in the negative skew of the data being analyzed. As there is a comparison of paired data pre- and post-intervention, a non-parametric test is necessary.

Types of Significance Tests

Significance tests are used to determine whether the results of a study are statistically significant or simply due to chance. The type of significance test used depends on the type of data being analyzed. Parametric tests are used for data that can be measured and are usually normally distributed, while non-parametric tests are used for data that cannot be measured in this way.

Parametric tests include the Student’s t-test, which can be paired or unpaired, and Pearson’s product-moment coefficient, which is used for correlation analysis. Non-parametric tests include the Mann-Whitney U test, which compares ordinal, interval, or ratio scales of unpaired data, and the Wilcoxon signed-rank test, which compares two sets of observations on a single sample. The chi-squared test is used to compare proportions or percentages, while Spearman and Kendall rank are used for correlation analysis.

It is important to choose the appropriate significance test for the type of data being analyzed in order to obtain accurate and reliable results. By understanding the different types of significance tests available, researchers can make informed decisions about which test to use for their particular study.

Individuals between the ages of 60 to 74 years are recommended to undergo bowel cancer screening every 2 years.

Colorectal Cancer Screening with FIT Test

Overview:
Colorectal cancer is often developed from adenomatous polyps. Screening for this cancer has been proven to reduce mortality by 16%. The NHS provides home-based screening for older adults through the Faecal Immunochemical Test (FIT). Although a one-off flexible sigmoidoscopy was trialled in England, it was abandoned in 2021 due to the inability to recruit enough clinical endoscopists, which was further exacerbated by the COVID-19 pandemic. However, the trial showed promising early results, and it remains to be seen whether flexible sigmoidoscopy will be used in future bowel screening programmes.

Faecal Immunochemical Test (FIT) Screening:
The NHS offers a national screening programme every two years to all men and women aged 60 to 74 years in England and 50 to 74 years in Scotland. Patients aged over 74 years may request screening. Eligible patients are sent FIT tests through the post. FIT is a type of faecal occult blood (FOB) test that uses antibodies that specifically recognise human haemoglobin (Hb). It is used to detect and quantify the amount of human blood in a single stool sample. FIT has advantages over conventional FOB tests as it only detects human haemoglobin, not animal haemoglobin ingested through diet. Only one faecal sample is needed compared to the 2-3 for conventional FOB tests. Although a numerical value is generated, this is not reported to the patient or GP. Instead, they will be informed if the test is normal or abnormal. Patients with abnormal results are offered a colonoscopy.

Colonoscopy:
Approximately 5 out of 10 patients will have a normal exam, 4 out of 10 patients will be found to have polyps that may be removed due to their premalignant potential, and 1 out of 10 patients will be found to have cancer.

Hormone Replacement Therapy (HRT) Options for Women

Women who have had a hysterectomy can use unopposed oestrogens, but those with a uterus must use regimens with both oestrogen and progestogen to avoid the risk of endometrial hyperplasia and potential malignant transformation. Postmenopausal women can use combined continuous regimens, while those still having periods can use cyclical HRT. Urogenital symptoms can be treated with topical oestrogens or non-hormonal vaginal moisturisers. Low dose combined pills may be an option for under 50s, but careful patient selection is necessary due to contraindications and cautions. It is important to discuss the risks and benefits of each option with a healthcare provider to determine the best course of treatment.

Rotavirus Immunisation Programme

The Rotavirus Immunisation Programme aims to prevent severe gastroenteritis caused by rotavirus by administering two doses of Rotarix® vaccine orally via a special applicator. However, the Department of Health Green Book advises that Rotarix® use is contraindicated in infants with certain conditions, such as a confirmed anaphylactic reaction to a previous dose of rotavirus vaccine or any components of the vaccine, a previous history of intussusception, and infants over 24 weeks of age. Additionally, infants with severe combined immune-deficiency, malformation of the gastrointestinal tract, and rare hereditary problems of fructose intolerance, glucose-galactose malabsorption, or sucrase-isomaltase insufficiency should not receive the vaccine.

Research has suggested that Rotarix® may be associated with a small increased risk of intussusception within seven days of vaccination, particularly in infants with a previous history of intussusception. The annual incidence of intussusception in the UK is 120 cases per 100,000 children below the age of 1, with a peak at 5 months of age. To minimize the risk of temporal association between rotavirus vaccination and intussusception, the first dose of the vaccine should not be administered after 15 weeks of age.

Due to the presence of a duodenal ulcer, diclofenac and indomethacin are not recommended for the patient. Instead, colchicine is a viable option. While allopurinol is effective in preventing future attacks, it should not be administered during the acute phase.

It is important to investigate the patient for conditions such as hypertension and ischaemic heart disease, which may be linked to gout.

Encouraging weight loss and advising the patient to avoid alcohol can be beneficial in managing gout.

Gout is caused by chronic hyperuricaemia and is managed acutely with NSAIDs or colchicine. Urate-lowering therapy (ULT) is recommended for patients with >= 2 attacks in 12 months, tophi, renal disease, uric acid renal stones, or prophylaxis if on cytotoxics or diuretics. Allopurinol is first-line ULT, with a delayed start recommended until inflammation has settled. Lifestyle modifications include reducing alcohol intake, losing weight if obese, and avoiding high-purine foods. Other options for refractory cases include febuxostat, uricase, and pegloticase.

Understanding Acute Asthma: Symptoms and Severity

Acute asthma is a condition that is typically observed in individuals who have a history of asthma. It is characterized by worsening dyspnea, wheezing, and coughing that doesn’t respond to salbutamol. Acute asthma attacks may be triggered by respiratory tract infections. Patients with acute severe asthma are classified into three categories: moderate, severe, or life-threatening.

Moderate acute asthma is characterized by a peak expiratory flow rate (PEFR) of 50-75% of the best or predicted value, normal speech, a respiratory rate (RR) of less than 25 breaths per minute, and a pulse rate of less than 110 beats per minute. Severe acute asthma is characterized by a PEFR of 33-50% of the best or predicted value, inability to complete sentences, an RR of more than 25 breaths per minute, and a pulse rate of more than 110 beats per minute. Life-threatening acute asthma is characterized by a PEFR of less than 33% of the best or predicted value, oxygen saturation levels of less than 92%, a silent chest, cyanosis or feeble respiratory effort, bradycardia, dysrhythmia or hypotension, and exhaustion, confusion, or coma.

It is important to note that a normal pCO2 in an acute asthma attack indicates exhaustion and should be classified as life-threatening. Understanding the symptoms and severity of acute asthma can help healthcare professionals provide appropriate treatment and management for patients experiencing an acute asthma attack.

Contraceptive Hormones and Pregnancy

Women who are using contraceptive hormones should not worry about any harm to the fetus if they become pregnant. It is not necessary to terminate the pregnancy for this reason. If the woman chooses to abort the pregnancy, the contraceptive implant can be left in place for ongoing contraception. Referral to an early pregnancy assessment unit or for an anomaly scan is also unnecessary as there is no risk to the fetus.

However, it is important to remove the progesterone-only implant as soon as pregnancy is confirmed. The only exception to this is if an intrauterine device is in place and pregnancy is diagnosed after 12 weeks. In such cases, the contraception should not be removed. Women can be reassured that contraceptive hormones are safe and effective for preventing pregnancy, and should not hesitate to use them if desired.

For patients with prosthetic heart valves, antithrombotic therapy varies depending on the type of valve. Bioprosthetic valves typically require aspirin, while mechanical valves require a combination of warfarin and aspirin.

Prosthetic Heart Valves: Options and Considerations

Prosthetic heart valves are commonly used to replace damaged or diseased valves in the heart. The two main options for replacement are biological (bioprosthetic) or mechanical valves. Bioprosthetic valves are usually derived from bovine or porcine sources and are preferred for older patients. However, they have a major disadvantage of structural deterioration and calcification over time. On the other hand, mechanical valves have a low failure rate but require long-term anticoagulation due to the increased risk of thrombosis. Warfarin is still the preferred anticoagulant for patients with mechanical heart valves, and the target INR varies depending on the valve location. Aspirin is only given in addition if there is an additional indication, such as ischaemic heart disease.

It is important to consider the patient’s age, medical history, and lifestyle when choosing a prosthetic heart valve. While bioprosthetic valves may not require long-term anticoagulation, they may need to be replaced sooner than mechanical valves. Mechanical valves, on the other hand, may require lifelong anticoagulation, which can be challenging for some patients. Additionally, following the 2008 NICE guidelines, antibiotics are no longer recommended for common procedures such as dental work for prophylaxis of endocarditis. Therefore, it is crucial to weigh the benefits and risks of each option and make an informed decision with the patient.

Guidelines for Switching Antidepressants

When switching antidepressants, it is important to follow specific guidelines to ensure a safe and effective transition. If switching from citalopram, escitalopram, sertraline, or paroxetine to another selective serotonin reuptake inhibitor (SSRI), the first SSRI should be gradually withdrawn before starting the alternative SSRI. However, if switching from fluoxetine to another SSRI, a gap of 4-7 days should be left after withdrawal due to its long half-life.

When switching from an SSRI to a tricyclic antidepressant (TCA), cross-tapering is recommended. This involves slowly reducing the current drug dose while slowly increasing the dose of the new drug. The exception to this is fluoxetine, which should be withdrawn before starting TCAs.

If switching from citalopram, escitalopram, sertraline, or paroxetine to venlafaxine, it is important to cross-taper cautiously. Starting with a low dose of venlafaxine (37.5 mg daily) and increasing very slowly is recommended. The same approach should be taken when switching from fluoxetine to venlafaxine.

Overall, following these guidelines can help minimize the risk of adverse effects and ensure a smooth transition when switching antidepressants.

Pierre-Robin syndrome is diagnosed in a baby who has micrognathia and a cleft palate. The baby is positioned in a prone position to alleviate upper airway obstruction. There is no familial history of similar conditions.

Childhood syndromes are a group of medical conditions that affect children and are characterized by a set of common features. Patau syndrome, also known as trisomy 13, is a syndrome that presents with microcephaly, small eyes, cleft lip/palate, polydactyly, and scalp lesions. Edward’s syndrome, or trisomy 18, is characterized by micrognathia, low-set ears, rocker bottom feet, and overlapping of fingers. Fragile X syndrome is a condition that causes learning difficulties, macrocephaly, a long face, large ears, and macro-orchidism. Noonan syndrome presents with a webbed neck, pectus excavatum, short stature, and pulmonary stenosis. Pierre-Robin syndrome is characterized by micrognathia, posterior displacement of the tongue, and cleft palate. Prader-Willi syndrome presents with hypotonia, hypogonadism, and obesity. William’s syndrome is characterized by short stature, learning difficulties, a friendly and extroverted personality, and transient neonatal hypercalcaemia. Finally, Cri du chat syndrome, also known as chromosome 5p deletion syndrome, presents with a characteristic cry due to larynx and neurological problems, feeding difficulties and poor weight gain, learning difficulties, microcephaly, micrognathism, and hypertelorism. It is important to note that Pierre-Robin syndrome has many similarities with Treacher-Collins syndrome, but the latter is autosomal dominant and usually has a family history of similar problems.

Factors that Increase the Risk of Suicide After an Attempt

When assessing a patient who has attempted suicide, certain factors can indicate a higher risk of future attempts. These include planning and taking precautions to avoid discovery, not seeking help after the attempt, using a dangerous method, and leaving final acts such as making a will or leaving a note. While a family history of suicide is more common among those who complete suicide, it doesn’t increase the immediate risk of self-harm. Alcohol use can lower inhibitions and increase the risk of deliberate self-harm, but being intoxicated at the time of the attempt doesn’t necessarily mean a higher risk of future attempts. Stressful life events in the preceding months can predispose to depression and increase the likelihood of self-harm, but do not necessarily indicate a higher risk of future attempts. Finally, taking a large amount of a dangerous substance may increase the risk of harm, but doesn’t confer a higher ongoing risk of suicide after the initial attempt. Overall, a comprehensive assessment of the patient’s mental state and risk factors is necessary to determine the appropriate level of care and support.

Factors to Consider When Assessing the Risk of Suicide After an Attempt

Treatment Options for Essential Tremor: A Comprehensive Guide

Essential tremor is a common neurological disorder that causes involuntary shaking of the hands, head, and voice. While there is no cure for essential tremor, there are several treatment options available to manage the symptoms.

Before starting any treatment, it is important to rule out any underlying peripheral or central nervous system disease and exclude possible causes of physiological tremor such as hyperthyroidism, drug-related tremor, or alcohol withdrawal.

The most appropriate first-line therapy for essential tremor is β blockade. If this is not tolerated, primidone is an alternative. Other medications that have shown effectiveness include alprazolam, atenolol, topiramate, and clonazepam. However, gabapentin has only been found to be effective when used as monotherapy and not as adjunct therapy.

For head tremors, botulinum toxin A can be used. In rare cases, surgery may be considered, such as deep brain stimulation or thalamotomy.

It is important to note that mild tremors may not require any treatment or only intermittent treatment for difficult social situations.

In conclusion, essential tremor can be managed with various treatment options. It is important to consult with a healthcare professional to determine the best course of action for each individual case.

Faecal Occult Blood Tests for Colorectal Cancer Screening

Faecal occult blood tests are recommended by NICE for patients who exhibit symptoms that may indicate colorectal cancer but are unlikely to have the disease. These tests are also used for routine screening. However, it is crucial to consider the criteria for suspected lower GI cancer referrals when deciding to use this test. For instance, if a patient is 60 years or older and has experienced a change in bowel habit, they should be referred using a suspected lower GI cancer pathway instead of undergoing a faecal occult blood test. Proper screening and referral protocols can help ensure timely and accurate diagnosis and treatment of colorectal cancer.

The sensitivity of 99.6 suggests that almost all patients with HIV are tested positive.

Precision refers to the consistency of a test in producing the same results when repeated multiple times. It is an important aspect of test reliability and can impact the accuracy of the results. In order to assess precision, multiple tests are performed on the same sample and the results are compared. A test with high precision will produce similar results each time it is performed, while a test with low precision will produce inconsistent results. It is important to consider precision when interpreting test results and making clinical decisions.

Liver Function and Statin Therapy

Liver function should be assessed before starting statin therapy. If liver transaminases are three times the upper limit of normal, statins should not be initiated. However, if the liver enzymes are elevated but less than three times the upper limit of normal, statin therapy can be used. It is important to repeat liver function tests within the first three months of treatment and then at 12 months, as well as if a dose increase is made or if clinically indicated.

In the case of a modest ALT elevation due to fatty deposition in the liver, statin therapy can still be beneficial for primary prevention, especially if the patient’s Qrisk2 score is over 10%. Mild derangement in liver function is not uncommon in overweight type 2 diabetics. The patient can be treated with the usual NICE-guided primary prevention dose of atorvastatin, which is 20 mg nocte. A higher dose or alternative statin may be required in the future, depending on the patient’s response to the initial treatment and lifestyle modifications. The slight ALT rise doesn’t necessarily require a lower statin dose.

When treating acne with oral antibiotics, tetracyclines are typically the first choice. All tetracyclines are effective for treating acne, so the decision on which one to use should be based on personal preference and cost. Tetracycline and oxytetracycline are taken twice a day on an empty stomach, while doxycycline and lymecycline are taken once a day and can be taken with food. However, pregnant or breastfeeding women and children under 12 should avoid oral tetracyclines due to the risk of them being deposited in the developing child’s teeth and bones. Women of childbearing age who are taking a topical retinoid should use effective contraception. If tetracyclines are not an option, erythromycin can be used instead at a dose of 500 mg twice a day. In this case, a 16-year-old female would be a suitable candidate for tetracyclines.

Acne vulgaris is a common skin condition that usually affects teenagers and is characterized by the obstruction of hair follicles with keratin plugs, resulting in comedones, inflammation, and pustules. The severity of acne can be classified as mild, moderate, or severe, depending on the number and type of lesions present. Treatment for acne typically involves a step-up approach, starting with single topical therapy and progressing to combination therapy or oral antibiotics if necessary. Tetracyclines are commonly used but should be avoided in certain populations, and a topical retinoid or benzoyl peroxide should always be co-prescribed to reduce the risk of antibiotic resistance. Combined oral contraceptives can also be used in women, and oral isotretinoin is reserved for severe cases under specialist supervision. Dietary modification has no role in the management of acne.

For patients with mild-moderate symptoms of carpal tunnel syndrome, conservative treatment with a wrist splint, with or without a steroid injection, should be attempted first. In this case, the woman’s symptoms suggest carpal tunnel syndrome and therefore, first-line management should involve conservative treatment before symptoms worsen. While amitriptyline may be useful for neuropathic pain, it is not the appropriate treatment in this case. Paracetamol and topical NSAIDs may be suitable for osteoarthritis involving the hands, but this presentation doesn’t suggest osteoarthritis. Surgical decompression may be necessary if symptoms worsen, but it is not the first-line treatment for mild-moderate symptoms. While a steroid injection may be appropriate when used in conjunction with wrist splinting, it is not typically the first-line treatment.

Carpal tunnel syndrome is a condition that occurs when the median nerve in the carpal tunnel is compressed. This can cause pain and pins and needles sensations in the thumb, index, and middle fingers. In some cases, the symptoms may even travel up the arm. Patients may shake their hand to alleviate the discomfort, especially at night. During an examination, weakness in thumb abduction and wasting of the thenar eminence may be observed. Tapping on the affected area may also cause paraesthesia, and flexing the wrist can trigger symptoms.

There are several potential causes of carpal tunnel syndrome, including idiopathic factors, pregnancy, oedema, lunate fractures, and rheumatoid arthritis. Electrophysiology tests may reveal prolongation of the action potential in both motor and sensory nerves. Treatment options may include a six-week trial of conservative measures such as wrist splints at night or corticosteroid injections. If symptoms persist or are severe, surgical decompression may be necessary, which involves dividing the flexor retinaculum.

Teething is a natural process where baby teeth emerge through the gums, usually starting around 6 months of age. Symptoms are generally mild and include pain, increased biting, drooling, gum-rubbing/sucking, irritability, wakefulness, and possibly a slight increase in temperature. The recommended initial management is to provide reassurance and advise on self-care measures such as gentle gum rubbing and allowing the child to bite on a clean and cool object. Paracetamol or ibuprofen suspension can be given to infants 3 months or older. It is not recommended to use choline salicylate gels, topical anaesthetics, or complementary therapies like herbal teething powder. A further dental opinion is not necessary as teething is a normal process.

Teething: Symptoms, Diagnosis, and Treatment Options

Teething is the process of primary tooth eruption in infants, which typically begins around 6 months of age and is usually complete by 30 months of age. It is characterized by a subacute onset of symptoms, including gingival irritation, parent-reported irritability, and excessive drooling. These symptoms occur in approximately 70% of all children and are equally prevalent in boys and girls, although girls tend to develop their teeth sooner than boys.

During examination, teeth can typically be felt below the surface of the gums prior to breaking through, and gingival erythema will be noted around the site of early tooth eruption. Treatment options include chewable teething rings and simple analgesia with paracetamol or ibuprofen. However, topical analgesics or numbing agents are not recommended, and oral choline salicylate gels should not be prescribed due to the risk of Reye’s syndrome.

It is important to note that teething doesn’t cause systemic symptoms such as fevers or diarrhea, and these symptoms should be treated as warning signs of other systemic illness. Additionally, teething necklaces made from amber beads on a cord are a common naturopathic treatment for teething symptoms but represent a significant strangulation and choking hazard. Therefore, it is crucial to avoid their use.

In conclusion, teething is a clinical diagnosis that can be managed with simple interventions. However, it is essential to be aware of potential hazards and to seek medical attention if systemic symptoms are present.

If the underlying cause is stated, it is acceptable to use a type of organ failure in 1a. However, section 2 should be used to record Type 2 diabetes mellitus as it doesn’t lead to essential hypertension.

Death Certification in the UK

There are no legal definitions of death in the UK, but guidelines exist to verify it. According to the current guidance, a doctor or other qualified personnel should verify death, and nurse practitioners may verify but not certify it. After a patient has died, a doctor needs to complete a medical certificate of cause of death (MCCD). However, there is a list of circumstances in which a doctor should notify the Coroner before completing the MCCD.

When completing the MCCD, it is important to note that old age as 1a is only acceptable if the patient was at least 80 years old. Natural causes is not acceptable, and organ failure can only be used if the disease or condition that led to the organ failure is specified. Abbreviations should be avoided, except for HIV and AIDS.

Once the MCCD is completed, the family takes it to the local Registrar of Births, Deaths, and Marriages office to register the death. If the Registrar decides that the death doesn’t need reporting to the Coroner, he/she will issue a certificate for Burial or Cremation and a certificate of Registration of Death for Social Security purposes. Copies of the Death Register are also available upon request, which banks and insurance companies expect to see. If the family wants the burial to be outside of England, an Out of England Order is needed from the coroner.

Differential Diagnosis for a Patient with Arthritis, Conjunctivitis, and nonspecific Urethritis

The patient presents with a classic triad of reactive arthritis, including arthritis, conjunctivitis, and nonspecific urethritis. This condition is often associated with human leukocyte antigen B27 and typically occurs after bacterial dysentery caused by Salmonella, Shigella, Campylobacter, or Yersinia spp. or sexually acquired infection with Chlamydia spp. Joint aspiration may reveal the presence of giant macrophages.

Other potential diagnoses include Behçet’s disease, which typically presents with recurrent oral and genital ulcers and uveitis, but is less likely in this case as there is no ulceration described. Sjögren syndrome, which produces dry eyes, dry mouth, and parotid enlargement, is also less likely as these symptoms are not present. Gonococcal arthritis, which can occur in sexually active patients, may present with a swollen knee, but the ocular and urinary tract symptoms are more consistent with reactive arthritis. Septic arthritis, which presents as a red, hot, swollen joint, is also a possibility, but joint aspiration would likely reveal the presence of Staphylococcus aureus.

Possible Causes of Chronic Constipation: A Differential Diagnosis

Chronic constipation is a common condition affecting approximately 14% of the global population. While most cases do not require investigation, it is important to consider potential underlying causes in certain patients. Here are some possible diagnoses to consider:

1. Idiopathic constipation: This is the most common cause of chronic constipation, especially in young patients. A high-fiber diet and physical activity can help alleviate symptoms.

2. Diverticular disease: This condition is characterized by abdominal pain and diarrhea, but it usually presents later in life and chronic constipation is a risk factor.

3. Colon cancer: While chronic constipation can be a symptom of colon cancer, other factors such as weight loss and rectal bleeding are usually present. This diagnosis is unlikely in younger patients.

4. Hypothyroidism: Constipation can be a symptom of an underactive thyroid, but other symptoms such as weight gain and fatigue are usually present.

5. Irritable bowel syndrome (IBS): IBS can cause constipation and/or diarrhea, but it is usually associated with abdominal pain and bloating.

In summary, chronic constipation can have various underlying causes, and a careful history and physical examination can help determine the appropriate diagnostic approach.

Antipsychotic Prescribing Guidelines for GPs: Consultation with Psychiatrists Recommended

Antipsychotic medication can be prescribed by GPs, but it is recommended that they consult with a psychiatrist before doing so. The drug of choice is an oral atypical antipsychotic, but prescribing doesn’t replace the need for a comprehensive multidisciplinary assessment in secondary care. A study among Irish GPs found that just over half reported prescribing antipsychotics for suspected schizophrenia, with positive symptoms being the most common reason. However, the majority always referred patients to psychiatric services. A low dose should be initiated and titrated up slowly to achieve optimum symptom control without side effects. If treatment fails, alternative atypical or low-potency first-generation antipsychotics can be considered. Recovery rates of 80% have been reported after a first episode of psychosis.

Chronic myeloid leukemia (CML) makes up to 5% of all leukemia cases.

Understanding Acute Lymphoblastic Leukaemia

Acute lymphoblastic leukaemia (ALL) is a type of cancer that commonly affects children, accounting for 80% of childhood leukaemias. It is most prevalent in children aged 2-5 years, with boys being slightly more affected than girls. Symptoms of ALL can be divided into those caused by bone marrow failure, such as anaemia, neutropaenia, and thrombocytopenia, and other features like bone pain, splenomegaly, hepatomegaly, fever, and testicular swelling.

There are three types of ALL: common ALL, T-cell ALL, and B-cell ALL. Common ALL is the most common type, accounting for 75% of cases, and is characterized by the presence of CD10 and pre-B phenotype. T-cell ALL accounts for 20% of cases, while B-cell ALL accounts for only 5%.

Certain factors can affect the prognosis of ALL, including age, white blood cell count at diagnosis, T or B cell surface markers, race, and sex. Children under 2 years or over 10 years of age, those with a WBC count over 20 * 109/l at diagnosis, and those with T or B cell surface markers, non-Caucasian, and male sex have a poorer prognosis.

Understanding the different types and prognostic factors of ALL can help in the early detection and management of this cancer. It is important to seek medical attention if any of the symptoms mentioned above are present.

Coeliac Disease in Children

Coeliac disease is a condition that affects young children, typically presenting by the age of 2 with failure to thrive. This occurs when gluten is introduced into their diet through the consumption of cereals. Symptoms include irritability, abdominal distention, buttock wasting, and abnormal stools due to malabsorption. Children can also present later on in childhood with anaemia or failure to thrive with very subtle or no gastrointestinal symptoms.

Diagnosis requires a jejunal biopsy for histological confirmation, and treatment is with a gluten-free diet. There appears to be a genetic link, and first-degree relatives of people with coeliac disease have a 1 in 10 chance of having the disease. Patients with coeliac disease also have a higher risk of type 1 diabetes, thyroid disease, and other autoimmune diseases.

It is important to consider offering testing (by tTG antibody testing) to first-degree relatives because a strict gluten-free diet is essential in reducing the associated risk of GI malignancy, especially lymphoma, in people with coeliac disease.

Causes of Hypertension with Renal Involvement

Hypertension with renal involvement has various causes, with renal impairment being the most common identifiable cause. Dipstick haematuria is a strong indicator of glomerulonephritis, particularly IgA nephropathy. However, if there is a family history and cerebral haemorrhage, autosomal dominant polycystic kidney disease (ADPKD) is a likely cause. ADPKD is the most common inherited cause of serious renal disease and often presents with hypertension and microscopic haematuria. Fibromuscular dysplasia of the renal arteries, which is autosomal dominant, may also cause hypertension but doesn’t present with haematuria. Renovascular atherosclerosis, on the other hand, causes hypertension but doesn’t show abnormal dipstick testing. A bruit may be audible in both fibromuscular dysplasia and renovascular atherosclerosis.

HIV and IV Drug Use: A Deadly Combination

Routine screening during pregnancy has revealed HIV prevalence rates ranging from 1 in 500 to 1 in 200 in certain areas of London, while parts of Edinburgh and Glasgow have estimated rates as high as 1 in 20 in areas with high IV drug abuse. At-risk groups in the UK now include an increasing number of heterosexual men. In sub-Saharan Africa and Latin America, heterosexuals account for the majority of cases, while HIV rates in the armies of the Democratic Republic of Congo and Angola are at least 50%.

Unfortunately, people who inject drugs face a higher risk of death, not just from HIV-related causes but also from drug overdose. However, early use of antiretroviral therapy has increased survival duration to near-normal and reduced the risk of developing AIDS. In fact, in the first five years of treatment, the death rate is the same as that of the general population, except for IV drug users, who have higher death rates.

In summary, HIV and IV drug use are a deadly combination, but with proper treatment and care, the risk of death can be significantly reduced.

Understanding Pes Cavus and its Association with Genetic Diseases

Pes cavus, also known as claw foot, is a condition characterized by an excessively arched foot that gives an unnaturally high instep. This condition is often associated with genetic diseases such as Charcot-Marie-Tooth (CMT) disease and Friedreich’s ataxia.

Friedreich’s ataxia is an autosomal recessive condition that affects the nervous system. It is characterized by progressive limb and gait ataxia, dysarthria, loss of proprioception and vibration sense, absent tendon reflexes in the lower limbs, and extensor plantar responses. The disease can also lead to pes cavus and scoliosis due to muscle weakness, as well as cardiomyopathy. Unfortunately, the disease is often debilitating, with more than 95% of those affected being wheelchair-bound by the age of 45 and an average life expectancy of approximately 50.

On the other hand, CMT affects both motor and sensory nerves and is often first noticed in adolescence or early adulthood. Symptoms include weakness of the foot and lower leg muscles, which may result in foot drop and a characteristic high-stepped gait. Weakness of the small muscles in the feet can lead to deformities such as pes cavus. In addition, the lower legs may take on an ‘inverted champagne bottle’ appearance due to the loss of muscle bulk. Although the disease can progress to affect the hands, it is not considered fatal, and people with most forms of CMT have a normal life expectancy.

In summary, understanding the association between pes cavus and genetic diseases such as CMT and Friedreich’s ataxia is crucial in diagnosing and managing these conditions. While Friedreich’s ataxia can be debilitating and life-threatening, CMT is generally not fatal, but can still significantly impact a person’s quality of life.

Dry macular degeneration, also known as drusen, is a common cause of visual loss in individuals over the age of 50. The accumulation of lipid and protein debris around the macula is a key indicator of this condition. Wet macular degeneration, on the other hand, is characterized by choroidal neovascularization. Hypertensive retinopathy is typically associated with blot hemorrhages and cotton wool spots, while microaneurysms can indicate either hypertensive retinopathy or diabetic retinopathy. However, given the patient’s normal blood pressure and HbA1c levels, it is less likely that these findings are present.

Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by degeneration of the central retina (macula) and the formation of drusen. The risk of ARMD increases with age, smoking, family history, and conditions associated with an increased risk of ischaemic cardiovascular disease. ARMD is classified into dry and wet forms, with the latter carrying the worst prognosis. Clinical features include subacute onset of visual loss, difficulties in dark adaptation, and visual hallucinations. Signs include distortion of line perception, the presence of drusen, and well-demarcated red patches in wet ARMD. Investigations include slit-lamp microscopy, colour fundus photography, fluorescein angiography, indocyanine green angiography, and ocular coherence tomography. Treatment options include a combination of zinc with anti-oxidant vitamins for dry ARMD and anti-VEGF agents for wet ARMD. Laser photocoagulation is also an option, but anti-VEGF therapies are usually preferred.

The Jaydess IUS is licensed for 3 years and has a smaller frame and less levonorgestrel than the Mirena coil. The Mirena coil is licensed for 5 years, while the Kyleena IUS has 19.5mg LNG and is also licensed for 5 years. The copper IUD is licensed for 5 years.

New intrauterine contraceptive devices include the Jaydess® IUS and Kyleena® IUS. The Jaydess® IUS is licensed for 3 years and has a smaller frame, narrower inserter tube, and less levonorgestrel than the Mirena® coil. The Kyleena® IUS has 19.5mg LNG, is smaller than the Mirena®, and is licensed for 5 years. Both result in lower serum levels of LNG, but the rate of amenorrhoea is less with Kyleena® compared to Mirena®.

Understanding Essential Tremor: A Common Movement Disorder

Essential tremor is the most prevalent movement disorder, characterized by a postural tremor that can occur between the ages of 20 and 60. It is a slowly progressive condition that can last for years. The exact cause of essential tremor is unknown, but it can be inherited or occur sporadically. The frequency of the tremor ranges from 4-11 Hz, depending on the affected body segment. Essential tremor most commonly affects the hands, but it can also affect the head, voice, tongue, and legs. In severe cases, the tremor may occur at rest. Interestingly, small amounts of alcohol can alleviate the tremor, which is not the case for Parkinson’s disease. The most commonly used drugs for essential tremor are propranolol and primidone, but other medications such as alprazolam, atenolol, gabapentin, and topiramate may also be effective. Understanding essential tremor is crucial for proper diagnosis and treatment.

Distinguishing between Vitamin B12 Deficiency and Multiple Sclerosis: Neurological Manifestations

Neurological manifestations can help distinguish between vitamin B12 deficiency and multiple sclerosis (MS). Vitamin B12 deficiency causes degeneration of the white matter in the dorsal and lateral columns of the spinal cord, peripheral nerves, optic nerves, and cerebral hemispheres. Chronic inhalation of nitrous oxide is an increasingly common cause of vitamin B12 deficiency. On the other hand, MS is a demyelinating disease that primarily affects the white matter of the brain, spinal cord, and optic nerves.

Sensory peripheral neuropathy, absent distal tendon reflexes, and distal sensory loss are neurological manifestations of vitamin B12 deficiency. In contrast, sensory loss consistent with peripheral neuropathy and absent ankle jerks are not features of MS. Ataxia, which is the lack of muscle coordination, is a feature of both subacute combined degeneration of the spinal cord and MS.

Barber’s chair sign, an electrical sensation that runs down the back and into the limbs, can be elicited by bending the head forward or lapping on the posterior cervical spine while the neck is flexed. It is caused by the involvement of the posterior columns and is most commonly associated with MS. However, it may also occur in other lesions of the cervical cord, such as cord compression, syringomyelia, and vitamin B12 deficiency.

Bilateral up-going plantar responses signify advanced subacute combined degeneration of the cord and pyramidal signs associated with MS. Optic atrophy, the degeneration of the optic nerve, is a common feature of MS and subacute combined degeneration of the cord.

DMARDs and Pulmonary Fibrosis

Many GP practices have a shared care relationship with rheumatologists to monitor and prescribe DMARDs for patients with rheumatoid arthritis. GPs involved in this care need to be knowledgeable about DMARD monitoring protocols and potential adverse effects. One such effect is pulmonary fibrosis, which can be caused by several DMARDs, including methotrexate, cyclophosphamide, sulphasalazine, and gold. Methotrexate is particularly well-known for causing lung fibrosis and interstitial pneumonitis, as well as blood dyscrasias and hepatic toxicity. Patients on methotrexate should be advised to seek medical attention if they experience dyspnoea, cough, or fever. It is important for GPs to be aware of these potential side-effects and to monitor patients accordingly.

Understanding Hypercalcaemia in Cancer Patients: The Role of PTHrP

Hypercalcaemia is a common occurrence in cancer patients, affecting around 10-20% of cases. It is caused by increased bone resorption and calcium release from bone, which can be triggered by osteolytic metastases, tumour secretion of parathyroid hormone-related peptide (PTHrP), and tumour production of calcitriol. Among these mechanisms, PTHrP secretion is the most common cause of hypercalcaemia in patients with non-metastatic solid tumours, also known as humoral hypercalcaemia of malignancy. This condition should be suspected in patients with solid tumours and unexplained hypercalcaemia, as well as those with low serum PTH concentration. Diagnosis can be confirmed by measuring high serum PTHrP concentration. While hypercalcaemia is often associated with advanced cancer and poor prognosis, understanding its underlying mechanisms can help in developing effective treatment strategies.