It is important to distinguish between risk and odds. For instance, if 100 individuals experience a myocardial infarction and 20 of them die, the risk of dying is 0.2 (20/100). However, the odds of dying are 0.25 (20/80).

Understanding Relative Risk in Clinical Trials

Relative risk (RR) is a measure used in clinical trials to compare the risk of an event occurring in the experimental group to the risk in the control group. It is calculated by dividing the experimental event rate (EER) by the control event rate (CER). If the resulting ratio is greater than 1, it means that the event is more likely to occur in the experimental group than in the control group. Conversely, if the ratio is less than 1, the event is less likely to occur in the experimental group.

To calculate the relative risk reduction (RRR) or relative risk increase (RRI), the absolute risk change is divided by the control event rate. This provides a percentage that indicates the magnitude of the difference between the two groups. Understanding relative risk is important in evaluating the effectiveness of interventions and treatments in clinical trials. By comparing the risk of an event in the experimental group to the control group, researchers can determine whether the intervention is beneficial or not.

The individual is experiencing sudden sensorineural hearing loss, which is typically of unknown cause. It is recommended that all patients begin treatment promptly with high dose steroids (60mg/day) for seven days, as this has been shown to improve outcomes. An ENT evaluation should be scheduled immediately to conduct pure tone audiometry testing and to rule out the presence of an acoustic neuroma through an MRI. In cases where oral steroids are ineffective, intra-tympanic steroids may be administered. Aciclovir is not typically prescribed as there is no evidence to support its efficacy.

Rinne’s and Weber’s Test for Differentiating Conductive and Sensorineural Deafness

Rinne’s and Weber’s tests are used to differentiate between conductive and sensorineural deafness. Rinne’s test involves placing a tuning fork over the mastoid process until the sound is no longer heard, then repositioning it just over the external acoustic meatus. A positive test indicates that air conduction (AC) is better than bone conduction (BC), while a negative test indicates that BC is better than AC, suggesting conductive deafness.

Weber’s test involves placing a tuning fork in the middle of the forehead equidistant from the patient’s ears and asking the patient which side is loudest. In unilateral sensorineural deafness, sound is localized to the unaffected side, while in unilateral conductive deafness, sound is localized to the affected side.

The table below summarizes the interpretation of Rinne and Weber tests. A normal result indicates that AC is greater than BC bilaterally and the sound is midline. Conductive hearing loss is indicated by BC being greater than AC in the affected ear and AC being greater than BC in the unaffected ear, with the sound lateralizing to the affected ear. Sensorineural hearing loss is indicated by AC being greater than BC bilaterally, with the sound lateralizing to the unaffected ear.

Overall, Rinne’s and Weber’s tests are useful tools for differentiating between conductive and sensorineural deafness, allowing for appropriate management and treatment.

When evaluating research articles, it is crucial to be aware of various biases and assess whether they have been minimized. If an article exhibits bias, its results may not be reliable. Some types of bias include response bias, where those who participate in a study may not accurately represent the population; observer bias, where the outcome may be influenced by the observer’s subjectivity; publication bias, where studies with negative findings are less likely to be published; and recall bias, where patients may more easily remember exposures they believe are linked to the outcome.

Detecting Publication Bias with Funnel Plots

Publication bias is a common issue in research where only studies with positive results are published, leading to biased overall results. To detect publication bias, graphical methods such as funnel plots and Galbraith plots can be used.

Among these methods, the funnel plot is the most commonly used and important for exams. A funnel plot is a scatter graph used to check for publication bias in systematic reviews and meta-analyses. It provides a visual representation of the weight of published literature, ensuring that all studies are evenly represented.

An asymmetrical, inverted funnel shape in a funnel plot indicates that publication bias is unlikely. However, an asymmetrical funnel shape indicates a relationship between treatment effect and study size, suggesting either publication bias or a systematic difference between smaller and larger studies known as small study effects. Therefore, funnel plots are a valuable tool for detecting publication bias and ensuring unbiased research results.

When answering questions about liver enzymes, it is crucial to determine whether the question pertains to induction or inhibition. Candidates should avoid hastily providing drugs that cause induction as the answer. Inhibited liver enzymes can result in an elevated INR. Additionally, isoniazid is known to inhibit the P450 system.

P450 Enzyme System and its Inducers and Inhibitors

The P450 enzyme system is responsible for metabolizing many drugs in the body. Induction of this system occurs when a drug or substance causes an increase in the activity of the P450 enzymes. This process usually requires prolonged exposure to the inducing drug. On the other hand, P450 inhibitors decrease the activity of the enzymes and their effects are often seen rapidly.

Some common inducers of the P450 system include antiepileptics like phenytoin and carbamazepine, barbiturates such as phenobarbitone, rifampicin, St John’s Wort, chronic alcohol intake, griseofulvin, and smoking. Smoking affects CYP1A2, which is the reason why smokers require more aminophylline.

In contrast, some common inhibitors of the P450 system include antibiotics like ciprofloxacin and erythromycin, isoniazid, cimetidine, omeprazole, amiodarone, allopurinol, imidazoles such as ketoconazole and fluconazole, SSRIs like fluoxetine and sertraline, ritonavir, sodium valproate, acute alcohol intake, and quinupristin.

It is important to be aware of the potential for drug interactions when taking medications that affect the P450 enzyme system. Patients should always inform their healthcare provider of all medications and supplements they are taking to avoid any adverse effects.

The use of Raloxifene is associated with an elevated risk of venous thromboembolism.

Therapeutic Management of Osteoporosis According to NICE Guidelines

Osteoporosis is a condition that affects bone density and increases the risk of fractures. The National Institute for Health and Care Excellence (NICE) has released guidelines on the therapeutic management of osteoporosis. The first-line treatment recommended by NICE is oral alendronate, taken once weekly at a dose of 70mg. If oral alendronate is not tolerated, NICE recommends the use of risk tables to determine whether it is worth trying another treatment. The tables display a minimum T score based on a patient’s age and number of clinical risk factors. If another treatment is indicated, alternative oral bisphosphonates such as risedronate or etidronate are recommended as the second-line treatment.

If bisphosphonates are not tolerated, NICE recommends reviewing risk tables again to see if further treatment is indicated. Strontium ranelate or raloxifene are recommended as alternative treatments. Strontium ranelate is a ‘dual action bone agent’ that increases the deposition of new bone by osteoblasts and reduces the resorption of bone by inhibiting osteoclasts. However, concerns regarding its safety profile have been raised recently, and it should only be prescribed by a specialist in secondary care. Raloxifene is a selective oestrogen receptor modulator (SERM) that has been shown to prevent bone loss and reduce the risk of vertebral fractures. It may worsen menopausal symptoms and increase the risk of thromboembolic events.

In summary, NICE guidelines recommend oral alendronate as the first-line treatment for osteoporosis, followed by alternative oral bisphosphonates if necessary. Strontium ranelate or raloxifene may be considered if bisphosphonates are not tolerated, but their use should be carefully monitored due to safety concerns. Clinical judgement may be required when determining the best course of action for individual patients.

Administer Benzylpenicillin IM 300 mg STAT to a child <= 11 months suspected of meningococcal disease before urgent hospital transfer. When suspected bacterial meningitis is being investigated and managed, it is important to prioritize timely antibiotic treatment to avoid negative consequences. Patients should be urgently transferred to the hospital, and if meningococcal disease is suspected in a prehospital setting, intramuscular benzylpenicillin may be given. An ABC approach should be taken initially, and senior review is necessary if any warning signs are present. A key decision is when to attempt a lumbar puncture, which should be delayed in certain circumstances. Management of patients without indication for delayed LP includes IV antibiotics, with cefotaxime or ceftriaxone recommended for patients aged 3 months to 50 years. Additional tests that may be helpful include blood gases and throat swab for meningococcal culture. Prophylaxis needs to be offered to households and close contacts of patients affected with meningococcal meningitis, and meningococcal vaccination should be offered to close contacts when serotype results are available.

The likely diagnosis in this case is septic arthritis, as indicated by the child’s reluctance to bear weight, distress, and fever with sweats. Although the child had a history of injury, this is not a significant factor as falls and accidents are common in toddlers. There is no indication of non-accidental injury, and the mother brought the child in for review due to his sudden illness. Developmental dysplasia of the hip is an unlikely cause of a new onset limp in a previously mobile child, while transient synovitis is uncommon in this age group and typically only causes mild illness.

Causes of Limping in Children Vary by Age

When a child is limping, the cause can vary depending on their age. For younger children, transient synovitis is a common cause. This condition has an acute onset and is often accompanied by viral infections, but the child is usually well or has a mild fever. It is more common in boys aged 2-12 years. On the other hand, septic arthritis/osteomyelitis is a more serious condition that causes a high fever and an unwell child.

Juvenile idiopathic arthritis can also cause a limp, which may be painless. Trauma is usually the cause of a limp in children, and the history of the injury can often diagnose the issue. Development dysplasia of the hip is usually detected in neonates and is six times more common in girls. Perthes disease is more common in children aged 4-8 years and is caused by avascular necrosis of the femoral head. Finally, slipped upper femoral epiphysis is a condition that occurs in children aged 10-15 years and is caused by the displacement of the femoral head epiphysis postero-inferiorly. Understanding the potential causes of a limp in children can help parents and healthcare providers identify and treat the issue promptly.

If a patient with coexistent hyperparathyroidism undergoes rapid vitamin D replacement, it can lead to toxicity. In the case of this woman, she requires urgent admission under the medical team due to severe hypercalcaemia. The cause is likely vitamin D toxicity and unidentified primary hyperparathyroidism. Previous blood tests indicate a severe vitamin D deficiency, but her calcium level is at the higher end of normal, suggesting an overactive parathyroid gland that was masked by the low vitamin D. Testing for parathyroid hormone prior to administering vitamin D could have clarified this. It is advisable to seek advice from endocrinology before rapid vitamin D replacement if the baseline corrected calcium is >2.5. While multiple myeloma can cause hypercalcaemia, it doesn’t occur as rapidly. Paget’s disease causes an increased ALP with a normal calcium level, and thyrotoxicosis due to Graves disease can cause hypercalcaemia due to increased bone turnover, but a suppressed TSH would be expected.

Vitamin D supplementation has been a topic of interest for several years, and recent releases have provided some clarity on the matter. The Chief Medical Officer’s 2012 letter and the National Osteoporosis Society’s 2013 UK Vitamin D guideline recommend that certain groups take vitamin D supplements. These groups include pregnant and breastfeeding women, children aged 6 months to 5 years, adults over 65 years, and individuals who are not exposed to much sun, such as housebound patients.

Testing for vitamin D deficiency is not necessary for most people. The NOS guidelines suggest that testing may be appropriate for patients with bone diseases that may be improved with vitamin D treatment, such as osteomalacia or Paget’s disease, and for patients with musculoskeletal symptoms that could be attributed to vitamin D deficiency, such as bone pain. However, patients with osteoporosis should always be given calcium/vitamin D supplements, and individuals at higher risk of vitamin D deficiency should be treated regardless of testing. Overall, vitamin D supplementation is recommended for certain groups, while testing for deficiency is only necessary in specific situations.

Epilepsy and Pregnancy: Considerations for Medication and Breastfeeding

Carbamazepine (CBZ) is present in breast milk, but only in small amounts. Breastfeeding mothers should be encouraged to continue breastfeeding as the levels of CBZ in breast milk are too low to cause any harm to the baby.

Prior to conception, it is recommended that women take folic acid at a dose of 5 mg daily to prevent neural tube defects in the fetus. However, it is not recommended for breastfeeding mothers.

For patients with well-controlled epilepsy, there is no increased risk of seizures during pregnancy or the postpartum period. While there is no routine need to monitor serum anti-epileptic concentrations, the NICE guidelines suggest monitoring levels in certain circumstances such as adjusting phenytoin dose, poor concordance, and suspected toxicity.

Overall, it is important for women with epilepsy to work closely with their healthcare provider to ensure the best possible outcomes for both mother and baby during pregnancy and breastfeeding.

Treatment Recommendations for Children and Young People with Depression

Children and young people who present with moderate to severe depression should be assessed by a CAMHS team. The first-line treatment for depression in this population is fluoxetine, as it is the only antidepressant for which the benefits outweigh the risks. According to NICE NG134, combined therapy with fluoxetine and psychological therapy should be considered as an alternative to psychological therapy followed by combined therapy for initial treatment of moderate to severe depression in young people aged 12-18 years. Patients taking St John’s wort should be advised to discontinue it when starting antidepressants. Tricyclics should not be used, and citalopram and sertraline are considered suitable second-line treatments.

Understanding the Probability of Inheriting Genetic Conditions

Trisomy 18, also known as Edwards syndrome, is a genetic condition that is usually inherited randomly and has a prevalence of around 1 in 6000 births in the UK. The condition is characterized by various physical abnormalities, including microcephaly, micrognathia, cleft palate, low-set, deformed ears, and rocker-bottom feet. The risk of trisomy 18 increases with maternal age, with the biggest increase after age 35.

If a couple has had one affected pregnancy, they are slightly more likely to have another affected pregnancy than the general population. In such cases, screening for a balanced translocation is recommended, which would further increase the risk.

The probability of inheriting a genetic condition depends on the type of inheritance pattern. For autosomal-recessive conditions, such as cystic fibrosis, if both parents are affected, there is a 25% chance of having an affected child. For autosomal-dominant conditions, such as Huntington’s disease, there is a 50% chance of inheriting the faulty gene, which will always be expressed if present.

However, in pre-implantation screening of embryos, genetic certainty of a condition being either present or absent can be achieved, resulting in a probability of 100%. It is important to understand the inheritance pattern and seek genetic counseling to assess the risk of passing on genetic conditions.

Public health is a crucial aspect of the RCGP curriculum, with a focus on promoting health and preventing disease. GPs are required to understand the surveillance systems involved in public health. An example of a health surveillance program in the UK is the National Child Measurement Program, which involves the continuous collection, analysis, and interpretation of health-related data for public health practice. Health protection involves safeguarding the public against health threats, such as air pollution or infectious diseases. Health promotion aims to empower individuals to improve their health, such as through education on healthy eating or access to smoking cessation services. Screening involves testing a population or subgroup for a disease in its early stages to provide early treatment and improve outcomes. Examples of screening programs in the UK include breast, cervical, and bowel cancer screening. Confidential enquiries are investigations into morbidity and mortality to identify areas for improvement, such as the annual Confidential Enquiry into Maternal and Child Health (CEMACH).

Understanding Health Promotion and Surveillance

Health promotion refers to the process of empowering individuals to take control of their health and improve it. This is achieved through various means such as education, awareness campaigns, and access to healthcare services. The World Health Organisation defines health promotion as a continuous process that enables people to increase their control over their health.

On the other hand, health surveillance is the systematic collection, analysis, and interpretation of health-related data. This data is used to plan, implement, and evaluate public health practices. Health surveillance is crucial in identifying health trends and patterns, which can help in the prevention and control of diseases. An example of health surveillance is the National Child Measurement Program, which collects data on childhood obesity.

In summary, health promotion and surveillance are essential components of public health. Health promotion empowers individuals to take control of their health, while health surveillance provides valuable data that can be used to plan and implement effective public health interventions.

A painless red eye that occurs suddenly is often caused by subconjunctival haemorrhage. This condition doesn’t affect the cornea and typically resolves on its own within two weeks. However, it is important to check the patient’s blood pressure as subconjunctival haemorrhage can rarely be linked to hypertension. On the other hand, a painful red eye may be caused by conditions such as herpes zoster ophthalmicus, scleritis, or uveitis. Conjunctivitis, which is characterized by a gritty sensation and ocular discharge, usually affects both eyes.

Subconjunctival haemorrhages occur when blood vessels in the subconjunctival space bleed. These vessels typically supply the conjunctiva or episclera. Trauma is the most common cause, followed by spontaneous idiopathic cases, Valsalva manoeuvres, and several systemic diseases. While subconjunctival haemorrhages can look alarming, they are rarely an indicator of anything serious. They are more common in women than men, and the risk increases with age. Newborns are also more susceptible. The incidence of both traumatic and non-traumatic subconjunctival haemorrhages is 2.6%.

Risk factors for subconjunctival haemorrhages include trauma, contact lens usage, idiopathic causes, Valsalva manoeuvres, hypertension, bleeding disorders, certain drugs, diabetes, arterial disease, and hyperlipidaemia. Symptoms include a red eye, usually unilateral, and mild irritation. Signs include a flat, red patch on the conjunctiva with well-defined edges and normal conjunctiva surrounding it. The patch’s size can vary depending on the size of the bleed and can involve the whole conjunctiva. Traumatic haemorrhages are most common in the temporal region, with the inferior conjunctiva as the next most commonly affected area. Vision should be normal, including acuity, visual fields, and range of eye movements. On examination, the fundus should be normal.

The diagnosis of a subconjunctival haemorrhage is clinical. If there is no obvious traumatic cause, check the patient’s blood pressure. If raised, refer the patient appropriately. If the patient is taking warfarin, check the INR. If raised, refer for appropriate adjustments to the dose to bring the INR back into the target range. If you cannot see the whole border of the haemorrhage, it may be associated with an intracranial bleed or an orbital roof fracture. Further appropriate investigations should then be done, including a full cranial nerve exam looking for neurological signs as well as a CT head, after discussion with a senior. Recurrent or spontaneous, bilateral subconjunctival haemorrhages warrant investigations for bleeding disorders or other pathology.

Reassure the patient that subconjunctival haemorrhages are a benign condition that will resolve on their own in 2 to 3 weeks.

For the treatment of asthma in children, the recommended dose of prednisolone is 1-2 mg/kg once daily for a period of 3-5 days.

The management of acute asthma attacks in children depends on the severity of the attack. Children with severe or life-threatening asthma should be immediately transferred to the hospital. For children with mild to moderate acute asthma, bronchodilator therapy and steroid therapy should be given. The dosage of prednisolone depends on the age of the child. It is important to monitor SpO2, PEF, heart rate, respiratory rate, use of accessory neck muscles, and other clinical features to determine the severity of the attack.

It is rare for patients of this age to exhibit the inspiratory ‘whoop’.

A vaccination programme for pregnant women was introduced in 2012 to combat an outbreak of whooping cough that resulted in the death of 14 newborn children. The vaccine is over 90% effective in preventing newborns from developing whooping cough. The programme was extended in 2014 due to uncertainty about future outbreaks. Pregnant women between 16-32 weeks are offered the vaccine.

Based on the examination results, it is unlikely that the patient is suffering from alcohol-induced peripheral neuropathy.

Understanding Morton’s Neuroma

Morton’s neuroma is a non-cancerous growth that affects the intermetatarsal plantar nerve, typically in the third inter-metatarsophalangeal space. It is more common in women than men, with a ratio of 4:1. The condition is characterized by pain in the forefoot, particularly in the third inter-metatarsophalangeal space, which worsens when walking. Patients may describe the pain as a shooting or burning sensation, and they may feel as though they have a pebble in their shoe. In addition, there may be a loss of sensation in the toes.

To diagnose Morton’s neuroma, doctors typically rely on clinical examination, although ultrasound may be helpful in confirming the diagnosis. One diagnostic technique involves attempting to hold the neuroma between the finger and thumb of one hand while squeezing the metatarsals together with the other hand. If a clicking sound is heard, it may indicate the presence of a neuroma.

Management of Morton’s neuroma typically involves avoiding high-heels and using a metatarsal pad. If symptoms persist for more than three months despite these measures, referral to a specialist may be necessary. Orthotists may provide patients with a metatarsal dome orthotic, while secondary care options may include corticosteroid injection or neurectomy of the affected interdigital nerve and neuroma.

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.

New Medical Driving Standards for Diabetic Drivers

The medical driving standards for individuals with diabetes have recently been updated. For those with a group 1 entitlement who are managed with insulin, it is required that they have awareness of hypoglycaemia and have not experienced more than one severe hypoglycaemic episode within the past 12 months. Appropriate blood glucose monitoring is also necessary. Severe hypoglycaemia is defined as an episode that requires external help, indicating that the individual is unable to treat the hypoglycaemia themselves.

It is important for these individuals to be informed of the DVLA guidance regarding insulin-treated diabetes and driving. They should also be advised to carry dextrose with them in case of an emergency. The DVLA has provided clear guidelines for patients on how diabetes can affect their ability to drive and what self-monitoring they should undertake. These guidelines are available as part of the ‘At a Glance Guide to the Current Medical Standards of Fitness to Drive for Medical Practitioners’, which is freely available online.

Causes of Dilated Cardiomyopathy: A Brief Overview

Dilated cardiomyopathy is a condition that often presents as congestive heart failure, with symptoms such as dyspnoea, fatigue, and weakness. There are several potential causes of dilated cardiomyopathy, including cocaine use, amyloidosis, and sarcoidosis.

Cocaine use can directly damage the heart, leading to heart failure, while amyloidosis can cause both dilated and restrictive cardiomyopathy. Sarcoidosis, a chronic inflammatory condition, is a rare cause of dilated cardiomyopathy.

Other substances, such as cannabis and benzodiazepines, are not typically associated with cardiomyopathy. However, chronic cannabis use can lead to other heart and lung conditions, while abrupt withdrawal from benzodiazepines can cause a rare form of cardiomyopathy called Takotsubo cardiomyopathy.

Overall, it is important to identify the underlying cause of dilated cardiomyopathy in order to provide appropriate treatment and management.

Understanding the Complications of Becker Muscular Dystrophy

Becker muscular dystrophy (BMD) is a genetic disorder that causes progressive muscle wasting and weakness. It typically presents with proximal muscle weakness and wasting, which can lead to the loss of independent walking between the ages of 20 and 60. BMD is inherited in an X-linked pattern, and a family history of the disease can help with diagnosis.

One of the most common complications of BMD is dilated cardiomyopathy, which occurs in 60-75% of those affected. This condition can be asymptomatic or cause dyspnea and fatigue, and it is the most common cause of death in BMD patients. Regular cardiac monitoring with an ECG and ECHO is recommended from diagnosis or ten years of age.

Hypertrophic cardiomyopathy is another genetic cardiovascular disease that can be inherited in an autosomal-dominant pattern. While most people with this condition are asymptomatic, some may present with dyspnea, chest pain, palpitations, or syncope.

Malignant hyperthermia is a rare but serious complication that can occur in BMD patients during general anesthesia. There is a link between the high creatine kinase levels present in muscular dystrophies and the progression to malignant hyperthermia following the stress of anesthesia.

Thyrotoxicosis is not associated with BMD, but it can cause myopathy and weakness. However, it would not normally cause wasting of the quadriceps, and it would not account for a family history of a wheelchair-bound uncle.

Urinary incontinence is also not associated with BMD. It is more commonly associated with multiple sclerosis, which can present with weakness. However, a diagnosis of MS would require evidence of another lesion disseminated in both time and space, making it less likely in this case.

Managing Gastro-Oesophageal Reflux Disease (GORD) with Alarm Symptoms

When managing someone with symptoms of gastro-oesophageal reflux disease (GORD), it is crucial to look for alarm features such as unintentional weight loss, dysphagia, GI bleeding, persistent vomiting, and signs of anaemia. Patients may report weight loss, which should be recorded periodically for comparisons. In the presence of alarm symptoms, it is important to refer urgently for upper GI endoscopy, especially for patients aged 55 and over with weight loss and upper abdominal pain, reflux, or dyspepsia. According to NICE guidelines, the referral should be made under the two-week wait. The positive serology to Helicobacter pylori nine years ago would not alter the management given the current presentation.

Onycholysis can be caused by Raynaud’s disease or any condition that affects blood flow.

Understanding Onycholysis: Causes and Symptoms

Onycholysis is a condition that occurs when the nail plate separates from the nail bed. This can be caused by a variety of factors, including trauma from excessive manicuring, fungal infections, skin diseases like psoriasis and dermatitis, impaired circulation in the extremities, and systemic diseases like hyper- and hypothyroidism. In some cases, the cause of onycholysis may be unknown, or idiopathic.

Symptoms of onycholysis can include a visible gap between the nail plate and nail bed, as well as discoloration or thickening of the nail. In some cases, the affected nail may become brittle or break easily.

According to BASHH, recurrent vaginal candidiasis is characterized by experiencing four or more episodes per year. This criterion is significant as it helps determine the need for prophylactic treatment to prevent future recurrences.

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.

Managing Nausea and Vomiting in Palliative Care: Medications to Consider

Nausea and vomiting are common symptoms in palliative care, and can be caused by a variety of factors such as drug toxicity or metabolic disturbances. To manage these symptoms, several medications can be considered.

Haloperidol is often the first-line drug for opioid-induced nausea, renal failure, and hypercalcaemia. Metoclopramide and levomepromazine are alternative options. For nausea caused by cytotoxic therapy or radiotherapy, ondansetron can be used.

Ranitidine may be beneficial if gastric or oesophageal stasis is an issue. Cyclizine is useful for managing vagally-mediated nausea and vomiting caused by mechanical bowel obstruction, vestibular disturbance, and Intracranial disease. Dexamethasone can be added to cyclizine in scenarios where Intracranial pressure is raised.

Finally, hyoscine butylbromide can be used for managing bowel colic and excessive gastrointestinal secretions. When selecting medications, it is important to consider the underlying cause of the nausea and vomiting, as well as the patient’s individual needs and preferences.

Viral labyrinthitis may cause hearing loss, while vestibular neuronitis doesn’t typically result in hearing loss. However, both conditions can cause symptoms such as nausea and vomiting, vertigo, and nystagmus. Therefore, the options stating that these symptoms are exclusive to one condition or the other are incorrect.

Vertigo is a condition characterized by a false sensation of movement in the body or environment. There are various causes of vertigo, each with its own unique characteristics. Viral labyrinthitis, for example, is typically associated with a recent viral infection, sudden onset, nausea and vomiting, and possible hearing loss. Vestibular neuronitis, on the other hand, is characterized by recurrent vertigo attacks lasting hours or days, but with no hearing loss. Benign paroxysmal positional vertigo is triggered by changes in head position and lasts for only a few seconds. Meniere’s disease, meanwhile, is associated with hearing loss, tinnitus, and a feeling of fullness or pressure in the ears. Elderly patients with vertigo may be experiencing vertebrobasilar ischaemia, which is accompanied by dizziness upon neck extension. Acoustic neuroma, which is associated with hearing loss, vertigo, and tinnitus, is also a possible cause of vertigo. Other causes include posterior circulation stroke, trauma, multiple sclerosis, and ototoxicity from medications like gentamicin.

Understanding the Athletic Heart

The athletic heart is a common occurrence in individuals who engage in prolonged periods of endurance training. It is characterized by a systolic flow murmur, LV enlargement, bradycardia, and third heart sounds. To differentiate it from cardiomyopathy, echocardiography is useful, with symmetric septal hypertrophy, normal diastolic function, and LVH <13 mm being features of athletic hearts. The BP response to exercise is normal, and LVH regresses in response to deconditioning. While persistent bradycardia and atrial arrhythmias are rare sequelae of the athletic heart picture, it is important to differentiate between a physiological S3 gallop (triple rhythm) and a pathological summation gallop. Although most GPs may struggle to differentiate third and fourth heart sounds, it is crucial to recognize that some signs can occur in 'normal' individuals as well as disease. Understanding the athletic heart is essential for healthcare professionals to provide appropriate care and treatment to their patients.

In this scenario, the BNF suggests administering half the usual oral dose of morphine.

When morphine is given through injection (subcutaneous, intramuscular, or intravenous), the recommended dose is approximately half of the oral dose. If the patient is no longer able to swallow, a continuous subcutaneous infusion of morphine is typically used.

Palliative care prescribing for pain is guided by NICE and SIGN guidelines. NICE recommends starting with regular oral modified-release or immediate-release morphine, with immediate-release morphine for breakthrough pain. Laxatives should be prescribed for all patients initiating strong opioids, and antiemetics should be offered if nausea persists. Drowsiness is usually transient, but if it persists, the dose should be adjusted. SIGN advises that the breakthrough dose of morphine is one-sixth the daily dose, and all patients receiving opioids should be prescribed a laxative. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred to morphine in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and all patients should be considered for referral to a clinical oncologist for further treatment. When increasing the dose of opioids, the next dose should be increased by 30-50%. Conversion factors between opioids are also provided. Opioid side-effects include nausea, drowsiness, and constipation, which are usually transient but may persist. Denosumab may be used to treat metastatic bone pain in addition to strong opioids, bisphosphonates, and radiotherapy.

Lacrimal Duct Problems: Dacryocystitis and Congenital Obstruction

Lacrimal duct problems can manifest in two ways: dacryocystitis and congenital obstruction. Dacryocystitis is an infection of the lacrimal sac that causes a watering eye (epiphora) and swelling and redness at the inner corner of the eye. Treatment involves systemic antibiotics, and intravenous antibiotics may be necessary if there is associated periorbital cellulitis.

On the other hand, congenital lacrimal duct obstruction affects 5-10% of newborns and is bilateral in 20% of cases. It causes a watering eye, even when the baby is not crying, and may lead to secondary infections. However, in 99% of cases, symptoms resolve by the time the baby reaches 12 months of age.

It is important to identify and manage lacrimal duct problems promptly to prevent complications and ensure proper eye health.

If a patient with otitis externa experiences worsening pain that doesn’t respond to strong painkillers, it is important to refer them urgently to an ENT specialist. This is especially true if the patient has a history of diabetes, as they are at a higher risk of developing malignant (necrotising) otitis externa. In advanced stages, this condition can cause facial nerve palsy on the same side as the affected ear. Treatment typically involves a long course of intravenous antibiotics, which is why prompt ENT assessment is crucial.

While oral antibiotics such as ciprofloxacin may be prescribed alongside ear drops if there is concern about deep tissue infection, most patients will require IV antibiotics. However, the priority in this situation is to escalate the case to an ENT specialist rather than focusing on pain relief or swabbing the ear canal. It is also important to avoid syringing the ear, as this can worsen the condition.

Malignant Otitis Externa: A Rare but Serious Infection

Malignant otitis externa is a type of ear infection that is uncommon but can be serious. It is typically found in individuals who are immunocompromised, with 90% of cases occurring in diabetics. The infection starts in the soft tissues of the external auditory meatus and can progress to involve the soft tissues and bony ear canal, eventually leading to temporal bone osteomyelitis.

Key features in the patient’s history include diabetes or immunosuppression, severe and persistent ear pain, temporal headaches, and purulent otorrhea. In some cases, patients may also experience dysphagia, hoarseness, and facial nerve dysfunction.

Diagnosis is typically done through a CT scan, and non-resolving otitis externa with worsening pain should be referred urgently to an ENT specialist. Treatment involves intravenous antibiotics that cover pseudomonas infections.

In summary, malignant otitis externa is a rare but serious infection that requires prompt diagnosis and treatment. Patients with diabetes or immunosuppression should be particularly vigilant for symptoms and seek medical attention if they experience persistent ear pain or other related symptoms.

According to NICE guidelines, patients who are aged 55 years or over and do not have type 2 diabetes or are of black African or African-Caribbean family origin and do not have type 2 diabetes (of any age) should be prescribed calcium-channel blockers as the first-line treatment for hypertension. In addition, this patient requires a statin for primary cardiovascular disease prevention.

Amlodipine alone is not sufficient as she requires both an antihypertensive agent and lipid-lowering therapy.

Atorvastatin and indapamide (a thiazide-like diuretic) is not the best option as indapamide is only recommended as a second-line antihypertensive agent if a calcium-channel blocker is contraindicated, not suitable or not tolerated.

Atorvastatin and ramipril is also not the best option as ACE inhibitors (or angiotensin-II receptor antagonists) are first-line for patients under the age of 55 and not of black African or African-Caribbean family origin, or those with type 2 diabetes (irrespective of age or family origin).

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.