Management of Persistent Hoarse Voice

A persistent hoarse voice for over three weeks is a ‘red flag’ presentation and should prompt urgent action to investigate for a suspected cancer, such as laryngeal or lung cancer. Risk factors such as smoking history and alcohol history are important to consider but would not alter your management plan.

NICE guidance on this changed slightly with the release of NG12. NICE advises that you should consider a suspected cancer pathway referral (for an appointment within 2 weeks) for laryngeal cancer in people aged 45 and over with persistent unexplained hoarseness.

It is important to note that a normal basic examination is not sufficient to rule out a sinister underlying cause. Hoarseness can also be caused by pulmonary pathology, and if you have any suspicions that this may be the case, you should arrange an urgent chest x-ray.

In summary, a persistent hoarse voice should be taken seriously and investigated promptly to rule out any potential underlying cancer or pulmonary pathology.

Due to the patient’s moderate-severe aortic stenosis, ACE inhibitors are contraindicated and a calcium channel blocker should be prescribed as the first-line treatment for hypertension. Alpha-blockers may be considered later in the treatment algorithm if necessary, typically at step 4 of the guidelines when potassium levels are high. While ACE inhibitors are typically recommended for patients with type 2 diabetes to protect the kidneys, they should not be used in this patient due to their aortic stenosis. Beta-blockers are not the first-line treatment for hypertension and are better suited for heart failure and post-myocardial infarction. They may be considered later in the treatment algorithm if needed, typically at step 4 when potassium levels are high.

Angiotensin-converting enzyme (ACE) inhibitors are commonly used as the first-line treatment for hypertension and heart failure in younger patients. However, they may not be as effective in treating hypertensive Afro-Caribbean patients. ACE inhibitors are also used to treat diabetic nephropathy and prevent ischaemic heart disease. These drugs work by inhibiting the conversion of angiotensin I to angiotensin II and are metabolized in the liver.

While ACE inhibitors are generally well-tolerated, they can cause side effects such as cough, angioedema, hyperkalaemia, and first-dose hypotension. Patients with certain conditions, such as renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema, should use ACE inhibitors with caution or avoid them altogether. Pregnant and breastfeeding women should also avoid these drugs.

Patients taking high-dose diuretics may be at increased risk of hypotension when using ACE inhibitors. Therefore, it is important to monitor urea and electrolyte levels before and after starting treatment, as well as any changes in creatinine and potassium levels. Acceptable changes include a 30% increase in serum creatinine from baseline and an increase in potassium up to 5.5 mmol/l. Patients with undiagnosed bilateral renal artery stenosis may experience significant renal impairment when using ACE inhibitors.

The current NICE guidelines recommend using a flow chart to manage hypertension, with ACE inhibitors as the first-line treatment for patients under 55 years old. However, individual patient factors and comorbidities should be taken into account when deciding on the best treatment plan.

Viral Causes of Sore Throat: Herpangina and Adenovirus

Herpangina is a viral infection caused by the Coxsackie A virus, which is most prevalent during the summer and autumn months. Although it primarily affects individuals under the age of 16, adults can also be affected. The virus is named after the town of Coxsackie in New York State. Fortunately, the infection is typically self-limiting.

Adenovirus is the most common viral cause of sore throat. Unlike herpangina, the degree of neck lymph node enlargement is usually minimal, and the throat may not appear red. However, the pain can be severe.

Patients with a serious mental health disorder and those taking antipsychotics may have their cardiovascular disease risk underestimated by QRISK2.

Management of Hyperlipidaemia: NICE Guidelines

Hyperlipidaemia, or high levels of lipids in the blood, is a major risk factor for cardiovascular disease (CVD). In 2014, the National Institute for Health and Care Excellence (NICE) updated their guidelines on lipid modification, which caused controversy due to the recommendation of statins for a significant proportion of the population over the age of 60. The guidelines suggest a systematic strategy to identify people over 40 years who are at high risk of CVD, using the QRISK2 CVD risk assessment tool. A full lipid profile should be checked before starting a statin, and patients with very high cholesterol levels should be investigated for familial hyperlipidaemia. The new guidelines recommend offering a statin to people with a QRISK2 10-year risk of 10% or greater, with atorvastatin 20 mg offered first-line. Special situations, such as type 1 diabetes mellitus and chronic kidney disease, are also addressed. Lifestyle modifications, including a cardioprotective diet, physical activity, weight management, alcohol intake, and smoking cessation, are important in managing hyperlipidaemia.

Taking Blood Specimens from Incapacitated Drivers

The BMA has provided clear guidance on the subject of taking blood specimens from incapacitated drivers. According to the 2010 document, the law allows for a blood specimen to be taken for future testing for alcohol or other drugs from a person involved in an accident who is unable to give consent due to medical reasons. A police constable must believe the person to be incapable of giving valid consent before a forensic physician is asked to take the sample. If this is not possible, another doctor may be asked, but not one who has any responsibility for the patient’s clinical care. The doctor to whom the request is made must take the specimen, and the doctor in charge of the patient’s care must be notified before the sample is taken. The specimen cannot be tested until the person regains competence and gives valid consent for it to be tested.

Under the Police Reform Act, it is no longer necessary to obtain consent from unconscious or incapacitated drivers. However, the sample is not tested until the person regains competence and gives valid consent to it being tested. A competent person who refuses to allow their sample to be tested may be liable to prosecution. It is important to note that the police have no powers to take and test blood specimens that were taken as part of the patient’s care in hospital. The new law recognises the duty to justice.

Patients with this condition often exhibit nonconformity to social norms, lack of remorse, deceitfulness, and irresponsibility. They may engage in unlawful behavior resulting in multiple arrests, get into fights due to aggressiveness, and be deceitful for personal gain. They may also disregard the safety of themselves and others and fail to support themselves financially. Despite their hurtful actions, they are unable to show remorse. Childhood problems such as truancy may be present, and their behavior can negatively impact family life. It is important to maintain confidentiality during the consultation.

Avoidant personality disorder is characterized by a fear of social contact and relationships due to a fear of criticism, rejection, or embarrassment. Patients view themselves as inferior to others and are hesitant to engage unless they are certain of being liked.

Borderline personality disorder is characterized by emotional instability, impulsive behavior, and unstable relationships with others. Patients may experience feelings of emptiness, have a poor self-image, and engage in self-harm.

Narcissistic personality disorder is characterized by an exaggerated sense of self-importance, lack of empathy, and a sense of entitlement.

Personality disorders are a set of maladaptive personality traits that interfere with normal functioning in life. They are categorized into three clusters: Cluster A, which includes odd or eccentric disorders such as paranoid, schizoid, and schizotypal; Cluster B, which includes dramatic, emotional, or erratic disorders such as antisocial, borderline, histrionic, and narcissistic; and Cluster C, which includes anxious and fearful disorders such as obsessive-compulsive, avoidant, and dependent. These disorders affect around 1 in 20 people and can be difficult to treat. However, psychological therapies such as dialectical behaviour therapy and treatment of any coexisting psychiatric conditions have been shown to help patients.

Pick’s disease, also known as frontotemporal dementia, is a type of dementia that typically affects individuals under the age of 65. This condition can manifest in various forms, with some patients experiencing changes in personality and behavior. In some cases, patients may also struggle with speech production and literacy skills, a condition known as primary progressive aphasia.

It is highly unlikely for a 40-year-old to develop Alzheimer’s disease or vascular dementia. Huntington’s disease, which is associated with dementia and personality changes, typically presents with motor dysfunction and tends to have a strong genetic component. While B12 deficiency can cause symptoms of dementia, it is often accompanied by other neurological changes, fatigue, and bowel issues.

Understanding Frontotemporal Lobar Degeneration

Frontotemporal lobar degeneration (FTLD) is a type of cortical dementia that is the third most common after Alzheimer’s and Lewy body dementia. There are three recognized types of FTLD: Frontotemporal dementia (Pick’s disease), Progressive non-fluent aphasia (chronic progressive aphasia, CPA), and Semantic dementia.

FTLD is characterized by an onset before 65, insidious onset, relatively preserved memory and visuospatial skills, personality change, and social conduct problems. Pick’s disease is the most common type of FTLD and is characterized by personality change and impaired social conduct. Other common features include hyperorality, disinhibition, increased appetite, and perseveration behaviors. Focal gyral atrophy with a knife-blade appearance is characteristic of Pick’s disease.

CPA is characterized by non-fluent speech, where the patient makes short utterances that are agrammatic. Comprehension is relatively preserved. Semantic dementia, on the other hand, is characterized by fluent progressive aphasia. The speech is fluent but empty and conveys little meaning. Unlike in Alzheimer’s, memory is better for recent rather than remote events.

In terms of management, NICE doesn’t recommend the use of AChE inhibitors or memantine in people with frontotemporal dementia. Understanding the different types of FTLD and their characteristics can aid in early diagnosis and appropriate management.

If a patient is suspected of having a TIA and is taking warfarin, a DOAC, or has a bleeding disorder, they must be admitted immediately for imaging to rule out a haemorrhage.

For patients without these conditions, administering 300 mg of aspirin immediately and then evaluating them by a specialist within 24 hours is recommended. The primary secondary prevention method is taking clopidogrel 75 mg once daily.

Referring patients to neurology as a routine measure would cause an unnecessary delay in treatment.

A transient ischaemic attack (TIA) is a brief period of neurological deficit caused by a vascular issue, lasting less than an hour. The original definition of a TIA was based on time, but it is now recognized that even short periods of ischaemia can result in pathological changes to the brain. Therefore, a new ’tissue-based’ definition is now used. The clinical features of a TIA are similar to those of a stroke, but the symptoms resolve within an hour. Possible features include unilateral weakness or sensory loss, aphasia or dysarthria, ataxia, vertigo, or loss of balance, visual problems, sudden transient loss of vision in one eye (amaurosis fugax), diplopia, and homonymous hemianopia.

NICE recommends immediate antithrombotic therapy, giving aspirin 300 mg immediately unless the patient has a bleeding disorder or is taking an anticoagulant. If aspirin is contraindicated, management should be discussed urgently with the specialist team. Specialist review is necessary if the patient has had more than one TIA or has a suspected cardioembolic source or severe carotid stenosis. Urgent assessment within 24 hours by a specialist stroke physician is required if the patient has had a suspected TIA in the last 7 days. Referral for specialist assessment should be made as soon as possible within 7 days if the patient has had a suspected TIA more than a week previously. The person should be advised not to drive until they have been seen by a specialist.

Neuroimaging should be done on the same day as specialist assessment if possible. MRI is preferred to determine the territory of ischaemia or to detect haemorrhage or alternative pathologies. Carotid imaging is necessary as atherosclerosis in the carotid artery may be a source of emboli in some patients. All patients should have an urgent carotid doppler unless they are not a candidate for carotid endarterectomy.

Antithrombotic therapy is recommended, with clopidogrel being the first-line treatment. Aspirin + dipyridamole should be given to patients who cannot tolerate clopidogrel. Carotid artery endarterectomy should only be considered if the patient has suffered a stroke or TIA in the carotid territory and is not severely disabled. It should only be recommended if carotid stenosis is greater

Causes of Galactorrhoea: Understanding the Link to Hypothyroidism

Galactorrhoea, the spontaneous flow of milk from the breast, can be caused by a variety of factors. Physiological causes include postpartum changes, hormonal fluctuations during puberty or menopause, and elevated prolactin levels due to conditions such as prolactinoma. Other medical conditions, such as chronic renal failure, bronchogenic carcinoma, and sarcoidosis, can also lead to galactorrhoea.

One lesser-known cause of galactorrhoea is primary hypothyroidism. This occurs when the thyroid gland fails to produce enough thyroid hormone, leading to increased levels of thyroid-releasing hormone and subsequent secretion of prolactin. The longer the hypothyroidism goes untreated, the more likely it is to cause hyperprolactinaemia and galactorrhoea.

It’s important to note that breast cancer and schizophrenia are not causes of galactorrhoea. While breast cancer may present with unilateral breast discharge, it is typically not milky. Schizophrenia itself doesn’t cause hyperprolactinaemia, but antipsychotic drugs used to treat the condition can. Other medications, such as antidepressants and spironolactone, can also produce galactorrhoea.

In summary, galactorrhoea can have a variety of causes, including physiological changes, medical conditions, and certain medications. Primary hypothyroidism is one potential cause that should not be overlooked, as it can lead to hyperprolactinaemia and galactorrhoea if left untreated.

The Controversy Surrounding PSA Testing for Prostate Cancer

The introduction of the prostate-specific antigen (PSA) test has led to increased awareness and earlier diagnosis of prostate cancer. However, the use of PSA testing for screening purposes remains controversial. While PSA is currently the best method for detecting localized prostate cancer and monitoring treatment response, it lacks specificity as it is also increased in patients with benign prostatic hypertrophy. Additionally, the effectiveness and cost-effectiveness of treating localized cancer is still uncertain.

Bone scans at diagnosis are likely unnecessary for patients with a PSA below 20 ng/ml, as bone metastases are unlikely at this level. Repeated bone scans during treatment are also unnecessary unless there are clinical indications, as repeated PSA tests are just as effective and more cost-effective. Biopsies under transrectal-ultrasound control are now commonly used for diagnosing prostate cancer, with a PSA exceeding 4 ng/ml being the usual indication for biopsy.

PSA is a protease produced exclusively by epithelial prostatic cells, both benign and malignant. It breaks down the high molecular weight protein of the seminal coagulum, resulting in more liquid semen. PSA testing is also useful for monitoring therapy in patients with prostate cancer.

Overall, the lack of specificity of the PSA test, combined with a lack of knowledge about the epidemiology and natural history of prostate cancer, are reasons against instituting a national screening program.