Managing Women’s Health after Renal Transplant: Contraception, Cancer Screening, and Vaccinations

Women who have undergone renal transplant and are of childbearing age should use effective contraception to prevent unintended pregnancy. The most effective methods include intrauterine contraceptive devices, etonogestrel implants, and depot medroxyprogesterone acetate. The latter is particularly suitable as it doesn’t interact with immunosuppressive drugs commonly used in transplant patients. While pregnancy is possible after a renal transplant, it is recommended to wait for at least a year and plan it carefully. Women should also manage their cardiovascular risk factors and keep up-to-date with vaccinations and cancer screening.

Renal transplant recipients have a higher incidence of cancer than the general population, so regular cancer screening is essential. Breast screening typically starts at 50 years, while cervical screening may not require additional tests. Warfarin is unlikely to be prescribed after a renal transplant, but if necessary, careful monitoring is required. Live vaccines, including Zostavax® shingles vaccine, should be avoided due to the risk of lower efficacy and immunosuppression. Instead, Shingrix® vaccine can be used where indicated.

Implants that require removal before cremation

Guidance for medical practitioners on the Ministry of Justice website states that certain implants pose a serious health and safety risk at the crematorium and must be removed before cremation. These include bone growth stimulators, radioactive iodine-125 seeds used in brachytherapy to the prostate, cardiac resynchronisation therapy devices, dental mercury amalgam, fixion nails, hydrocephalus programmable shunts, implantable cardioverter defibrillators, implantable drug pumps, implantable loop recorders, neurostimulators, pacemakers, ventricular assist devices, and any other battery-powered implant.

However, the British Cochlear Implant Group states that it is currently not necessary to remove cochlear implants before cremation as they will not explode. Although some crematoriums may require all implantable devices to be removed, parts of the implant may still remain after cremation. If new implants with batteries contained in the internal device become available in the future, it will be necessary to remove them before cremation.

Diagnosis of CKD and Hypertension: NICE Guidelines

The National Institute for Health and Care Excellence (NICE) has provided guidelines for the diagnosis of chronic kidney disease (CKD) and hypertension. To diagnose CKD, more than one estimated glomerular filtration rate (eGFR) reading below 60 is required over a period of three months. Similarly, hypertension should not be diagnosed based on a single blood pressure reading, but rather through ambulatory or home blood pressure monitoring. Acute kidney injury is characterized by a significant increase in serum creatinine or oliguria, and eGFR is not a reliable indicator for its diagnosis. NICE also recommends using eGFRcystatinC to confirm or rule out CKD in individuals with an eGFR of 45-59 ml/min/1.73 m2, sustained for at least 90 days, and no proteinuria or other markers of kidney disease.

Measles: Key Points to Remember

– Prophylactic antibiotics are not effective in treating measles.
– Koplik spots are a unique symptom of measles.
– Erythromycin doesn’t reduce the duration of measles.
– The MMR vaccine is typically given to children between 12-15 months of age.
– The rash associated with measles is widespread and different from the vesicular rash of Chickenpox.

Measles is a highly contagious viral infection that can cause serious complications, particularly in young children. It is important to remember that prophylactic antibiotics are not effective in treating measles, and erythromycin doesn’t shorten the duration of the illness. One unique symptom of measles is the presence of Koplik spots, which are small white spots that appear on the inside of the mouth. The MMR vaccine is the most effective way to prevent measles and is typically given to children between 12-15 months of age. Finally, it is important to note that the rash associated with measles is widespread and different from the vesicular rash of Chickenpox.

Understanding Alcohol Withdrawal Symptoms

Alcohol withdrawal symptoms can manifest in different ways depending on the severity of the addiction. DTs or delirium tremens usually occur 2-4 days after stopping drinking and are characterized by severe agitation, confusion, and hallucinations. On the other hand, tremulousness or withdrawal convulsions can occur during a drinking spree or within a few hours of cessation. Alcoholic hallucinosis, which is characterized by auditory hallucinations, can occur over days or weeks. However, it is less severe than DTs.

Admission to a medical facility for appropriate sedation, nursing support, and thiamine replacement is necessary to manage the symptoms and prevent complications. Understanding the different alcohol withdrawal symptoms can help you identify when someone needs medical attention and provide the necessary support.

Acute Testicular Pain in Young Males: Torsion as the Primary Concern

In young males under 20 years of age who experience sudden testicular pain, it is crucial to consider torsion as the primary diagnosis. Failure to recognize this condition can lead to irreversible damage to the testes. Therefore, the most important action is to seek immediate medical attention and admission for acute urology opinion.

Prompt treatment within six hours of symptom onset can save most testes, while delaying treatment beyond 12 hours can result in the loss of the affected testicle. Therefore, it is essential to prioritize timely diagnosis and management of testicular torsion to prevent long-term complications and preserve fertility.

As per the Children Act 1989, families are restricted to fostering a maximum of three children.

Foster care is a system in which children who cannot live with their birth families are placed with foster families who provide them with a safe and nurturing environment. According to Schedule 7 of the Children Act 1989, there is a limit of three foster children per family. Additionally, all children in long-term foster care require a medical examination every six months to ensure their physical and emotional well-being. This system aims to provide children with stability and support while their birth families work towards resolving any issues that led to their placement in foster care.

Understanding Occupational Asthma

Occupational asthma is a type of asthma that is caused by conditions and factors present in a particular work environment. It is characterized by variable air flow limitation and/or airway hyper-responsiveness. This type of asthma accounts for about 10% of adult asthma cases.

To diagnose occupational asthma, there are several investigations that are proven to be effective. These include serial peak flow measurements at and away from work, specific IgE assay or skin prick testing, and specific inhalation testing. If there is a consistent fall in peak flow values and increased intraday variability on working days, and improvement on days away from work, then occupational asthma is confirmed.

It is important to understand occupational asthma and its causes to prevent and manage this condition effectively. Proper diagnosis and management can help individuals continue to work safely and maintain their quality of life.

According to the 2008 NICE guidelines, if a patient cannot tolerate alendronate, it is recommended to switch to risedronate or etidronate.

Osteoporosis is a condition that weakens bones, making them more prone to fractures. The National Institute for Health and Care Excellence (NICE) has updated its guidelines on the management of osteoporosis in postmenopausal women. Treatment is recommended for women who have confirmed osteoporosis following fragility fractures. Vitamin D and calcium supplements should be offered to all women unless they have adequate intake. Alendronate is the first-line treatment, but if patients cannot tolerate it, risedronate or etidronate may be given. Strontium ranelate and raloxifene are recommended if bisphosphonates cannot be taken. Treatment criteria for patients not taking alendronate are complex and based on age, T-score, and risk factors. Bisphosphonates have been shown to reduce the risk of fractures, while vitamin D and calcium supplements have a poor evidence base. Raloxifene, strontium ranelate, and denosumab are other treatment options, but they have potential side effects and should only be prescribed by specialists. Hormone replacement therapy is no longer recommended for osteoporosis prevention due to concerns about increased rates of cardiovascular disease and breast cancer. Hip protectors and falls risk assessments may also be considered in the management of high-risk patients.

Dermatological Conditions in Pregnancy

During pregnancy, there are specific dermatological conditions that should be considered when assessing a skin complaint. However, it is important to note that pregnancy doesn’t exclude the usual causes of rashes, and infectious causes must also be considered as they may pose a risk to the developing fetus.

One such condition is pemphigoid gestationis (PG), an autoimmune blistering condition that causes fluid-filled blisters on an itchy rash, typically starting around the umbilicus. Topical steroids and oral antihistamines are used for milder cases, while oral steroids may be necessary for more severe disease.

Cholestasis of pregnancy causes generalised pruritus, particularly affecting the palms and soles, and is typically seen in the latter half of pregnancy. Symptoms resolve after delivery, but recurrence occurs in up to 40% of pregnancies. Abnormal liver function tests are also seen.

Parvovirus, although uncommon in pregnancy, can cause serious fetal complications, including hydrops, growth retardation, anaemia, and hepatomegaly. It typically causes a slapped cheek rash followed by a lace-pattern rash on the limbs and trunk. Approximately 1 in 10 of those affected in the first half of pregnancy will miscarry, and in the remainder, there is a 1% risk of congenital abnormality.

Polymorphic eruption of pregnancy, also known as pruritic urticarial papules and plaques of pregnancy (PUPPP), is characterised by an itchy rash of pink papules that occurs in the stretch marks of the abdomen in the third trimester. It clears with delivery and is thought to be related to an allergy to the stretch marks.

Varicella can cause a vesicular rash, but the description of tense blisters in combination with the rash distribution and other features are typical of PG.

Patients who are on long-term steroids or methotrexate and have weakened immune systems should be given VZIG if they come into contact with Chickenpox and have no antibodies to varicella. Although Chickenpox is usually a mild illness, it can be dangerous for those who are immunosuppressed or pregnant.

If a patient has been exposed to varicella, they should be offered active post-exposure prophylaxis with varicella-zoster immunoglobulin. It is important to test people who have had significant exposure to Chickenpox and are immunocompromised for varicella-zoster antibody, regardless of their history of Chickenpox.

It is inappropriate to wait for up to 21 days to see if symptoms appear or take no action because this patient is immunosuppressed and is at risk of severe varicella infection. Similarly, stopping her methotrexate would not be appropriate as the immunosuppressive effects would take time to wear off.

Managing Chickenpox Exposure in At-Risk Groups

Whilst Chickenpox is usually a mild condition in children with normal immune systems, it can cause serious systemic disease in at-risk groups. Pregnant women and their developing fetuses are particularly vulnerable. Therefore, it is crucial to know how to manage varicella exposure in these special groups.

To determine who would benefit from active post-exposure prophylaxis, the following criteria should be met: significant exposure to Chickenpox or herpes zoster, a clinical condition that increases the risk of severe varicella (such as immunosuppression), and no antibodies to the varicella virus. Ideally, all at-risk exposed patients should have a blood test for varicella antibodies. However, post-exposure prophylaxis should not be delayed past 7 days after initial contact.

Patients who meet the above criteria should be given varicella-zoster immunoglobulin (VZIG). The management of Chickenpox exposure in pregnancy is an important topic that is covered in more detail in a separate entry to the textbook.

Type II error – the false hypothesis is not rejected when it is true.

Significance tests are used to determine the likelihood of a null hypothesis being true. The null hypothesis states that two treatments are equally effective, while the alternative hypothesis suggests that there is a difference between the two treatments. The p value is the probability of obtaining a result by chance that is at least as extreme as the observed result, assuming the null hypothesis is true. Two types of errors can occur during significance testing: type I, where the null hypothesis is rejected when it is true, and type II, where the null hypothesis is accepted when it is false. The power of a study is the probability of correctly rejecting the null hypothesis when it is false, and it can be increased by increasing the sample size.

Treatment Options for Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) is a common condition in men, characterized by troublesome symptoms such as difficulty urinating. There are several treatment options available, depending on the severity of symptoms and the size of the prostate.

Alpha-blockers, such as tamsulosin, are usually the first-line treatment for men with moderate-to-severe voiding symptoms. These drugs reduce the tone in the muscle of the neck of the bladder, providing relief within days.

5-alpha-reductase inhibitors, such as finasteride, can be offered to men with symptoms. These drugs block the synthesis of dihydrotestosterone from testosterone and can reduce symptoms, but it may take several months before benefit is noted.

Oral desmopressin, an analogue of antidiuretic hormone, can be used when nocturnal polyuria is the predominant symptom and there is no other obvious treatable cause.

Goserelin, a gonadorelin analogue, is used in the treatment of prostate cancer. Given the examination findings of a smoothly enlarged prostate and a normal PSA, prostate cancer is unlikely.

Antimuscarinic drugs, such as oxybutynin, can be added for men with a mixed picture of voiding and storage symptoms. However, for men with predominantly voiding symptoms and signs of BPH on examination, oxybutynin would not be first line.

In summary, treatment options for BPH depend on the individual’s symptoms and prostate size. Alpha-blockers and 5-alpha-reductase inhibitors are commonly used, while desmopressin and goserelin are reserved for specific cases. Antimuscarinic drugs may be added for men with mixed symptoms, but are not first-line for those with predominantly voiding symptoms.

Measles and MMR Vaccination Guidelines

Significant contact with measles is defined as being in the same room as an infected individual for 15 minutes or more. If an individual has not been fully immunised or has not previously had laboratory confirmed measles, it is assumed that they lack immunity. This is important to note for children who have not received the MMR vaccination for no good reason, as family history of epilepsy or autism is not a contraindication.

Ideally, the MMR vaccine should be given within three days of contact with a possible case of measles. A repeat MMR vaccine should be given after at least a month. The first dose of MMR should be given between 12 and 13 months of age, within a month of the first birthday. Immunisation before one year of age provides earlier protection in localities where the risk of measles is higher, but residual maternal antibodies may reduce the response rate to the vaccine. The optimal age chosen for scheduling children is therefore a compromise between risk of disease and level of protection.

If a dose of MMR is given before the first birthday, either because of travel to an endemic country or because of a local outbreak, then this dose should be ignored, and two further doses given at the recommended times between 12 and 13 months of age and at three years four months to five years of age. During the 2012-13 outbreak in Wales, a recommendation was made about the possibility of withdrawal from educational establishments for unvaccinated close contacts.

It is important to follow these guidelines to prevent the spread of measles and protect individuals who may be at risk.

Meralgia paraesthetica is a condition that occurs when the lateral cutaneous nerve of the thigh is compressed, resulting in burning and numbness in the upper lateral portion of the thigh. This condition typically affects only one side of the body and doesn’t cause any motor deficits. Symptoms may worsen with hip extension or prolonged standing, but sitting down can provide temporary relief.

Femoral neuropathy, on the other hand, affects both the sensory and motor functions of the muscles innervated by the nerve. While burning pain and paraesthesia may be present, weakness in the legs, especially when climbing stairs, is also a common symptom. A hip and knee exam may reveal abnormalities such as weakness when extending or flexing these joints.

Referred lumbar radiculopathy is another condition that can cause leg pain, but the pain is typically located in the back of the leg rather than the upper-lateral portion. The pain is often described as a shooting pain, and patients may also experience motor deficits.

Superior cluneal nerve dysfunction can also cause burning pain and paraesthesia, but this condition affects the lower back and upper gluteal area rather than the thigh.

Understanding Meralgia Paraesthetica

Meralgia paraesthetica is a condition characterized by paraesthesia or anaesthesia in the distribution of the lateral femoral cutaneous nerve (LFCN). It is caused by entrapment of the LFCN, which can be due to various factors such as trauma, iatrogenic causes, or neuroma. Although not rare, it is often underdiagnosed.

The LFCN is a sensory nerve that originates from the L2/3 segments and runs beneath the iliac fascia before exiting through the lateral aspect of the inguinal ligament. Compression of the nerve can occur anywhere along its course, leading to the development of meralgia paraesthetica. The condition is more common in men than women and is often seen in those with diabetes or obesity.

Symptoms of meralgia paraesthetica include burning, tingling, numbness, and shooting pain in the upper lateral aspect of the thigh. These symptoms are usually aggravated by standing and relieved by sitting. Diagnosis can be made through the pelvic compression test, which is highly sensitive, or through nerve conduction studies. Treatment options include injection of the nerve with local anaesthetic or surgical decompression.

In conclusion, meralgia paraesthetica is a condition that can cause significant discomfort and restriction in patients. Understanding its causes, symptoms, and diagnostic methods can aid in its timely diagnosis and management.

Assessment and Severity of Acute Asthma

Assessment and severity of acute asthma are common topics in exams. The British Thoracic Society provides clear guidance on the assessment and management of acute asthma, which should be familiar to healthcare professionals.

Indicators of acute severe asthma include a peak expiratory flow rate of 33-50% of best or predicted, a respiratory rate of 25 or greater, a heart rate of 110/min or greater, or an inability to complete sentences in one breath. The aim of oxygen therapy is to maintain SpO2 94-98%.

In the case of this man, the only indicator of an acute severe asthma attack is a respiratory rate of >25. If any of these features persist after initial treatment, the patient should be admitted. It is important for healthcare professionals to be aware of these indicators and to follow the appropriate management guidelines to ensure the best possible outcome for the patient.

Triptans can serve as a form of preventive treatment for menstrual migraines, known as mini-prophylaxis.

Managing Migraines: Guidelines and Treatment Options

Migraines can be debilitating and affect a significant portion of the population. To manage migraines, it is important to understand the different treatment options available. The National Institute for Health and Care Excellence (NICE) has provided guidelines for the management of migraines.

For acute treatment, a combination of an oral triptan and an NSAID or paracetamol is recommended as first-line therapy. For young people aged 12-17 years, a nasal triptan may be preferred. If these measures are not effective or not tolerated, a non-oral preparation of metoclopramide or prochlorperazine may be offered, along with a non-oral NSAID or triptan.

Prophylaxis should be considered if patients are experiencing two or more attacks per month. NICE recommends either topiramate or propranolol, depending on the patient’s preference, comorbidities, and risk of adverse events. Propranolol is preferred in women of childbearing age as topiramate may be teratogenic and reduce the effectiveness of hormonal contraceptives. Acupuncture and riboflavin may also be effective in reducing migraine frequency and intensity.

For women with predictable menstrual migraines, frovatriptan or zolmitriptan may be used as a type of mini-prophylaxis. Specialists may also consider candesartan or monoclonal antibodies directed against the calcitonin gene-related peptide (CGRP) receptor, such as erenumab. However, pizotifen is no longer recommended due to common adverse effects such as weight gain and drowsiness.

It is important to exercise caution with young patients as acute dystonic reactions may develop. By following these guidelines and considering the various treatment options available, migraines can be effectively managed and their impact on daily life reduced.

Causes of Pathological Fractures in the Elderly

Pathological fractures are fractures that occur due to weakened bones caused by underlying medical conditions. While any type of bone tumour can cause pathological fractures, the majority of cases in the elderly are due to metastatic carcinomas. This is because as people age, their risk of developing cancer increases. Multiple myeloma, a type of cancer that affects the bone marrow, is also common in the elderly and has a high incidence of pathological fractures. Lymphoma, although uncommon, can also cause pathological fractures.

It is important to keep this information in mind when evaluating elderly patients who present with musculoskeletal problems such as shoulder or back pain. A thorough medical history and physical examination can help identify the underlying cause of the fracture and guide appropriate treatment. By understanding the common causes of pathological fractures in the elderly, healthcare providers can provide better care and improve patient outcomes.

Understanding Folic Acid Deficiency and Supplementation

Folic acid is an essential nutrient that plays a crucial role in fetal development and overall health. Inadequate intake of folic acid can lead to various health problems, including neural tube defects in the fetus. Pregnant women are particularly at risk and are advised to take folic acid supplements to meet their increased requirements.

Contrary to popular belief, intestinal bacterial overgrowth is not a common cause of folic acid deficiency. Instead, reduced intake is the primary cause, and deficiency can develop rapidly within four months in people with an inadequate diet. It is important to note that folic acid deficiency can cause megaloblastic anemia, but it doesn’t typically result in neurological symptoms like vitamin B12 deficiency.

Methotrexate, a drug used to treat various conditions, can impair folate utilization and cause megaloblastic anemia. Concomitant folic acid supplementation can reduce the overall toxicity of the drug without affecting its efficacy. However, it is recommended to avoid taking folic acid on the same day as methotrexate to prevent adverse effects on absorption.

In summary, understanding folic acid deficiency and supplementation is crucial for maintaining overall health, especially during pregnancy and when taking certain medications. Adequate intake of folic acid can prevent various health problems and improve overall well-being.

PSA Testing for Prostate Cancer

Prostate specific antigen (PSA) is an enzyme produced by the prostate gland, and it is used as a tumour marker for prostate cancer. However, there is still much debate about its usefulness as a screening tool. The NHS Prostate Cancer Risk Management Programme (PCRMP) has published guidelines on how to handle requests for PSA testing in asymptomatic men. The National Screening Committee has decided not to introduce a prostate cancer screening programme yet, but rather allow men to make an informed choice.

The PCRMP has recommended age-adjusted upper limits for PSA, while NICE Clinical Knowledge Summaries suggest a lower threshold for referral. However, PSA levels may also be raised by other conditions such as benign prostatic hyperplasia, prostatitis, urinary tract infection, ejaculation, vigorous exercise, urinary retention, and instrumentation of the urinary tract.

PSA testing has poor specificity and sensitivity, and various methods are used to try and add greater meaning to a PSA level, including age-adjusted upper limits and monitoring change in PSA level with time. It is important to note that digital rectal examination may or may not cause a rise in PSA levels, which is a matter of debate.

The prophylaxis of oesophageal bleeding can be achieved using a non-cardioselective B-blocker (NSBB), while endoscopic sclerotherapy is no longer considered effective in preventing variceal haemorrhage.

Variceal haemorrhage is a serious condition that requires prompt and effective management. The initial treatment involves resuscitation of the patient, correction of clotting abnormalities, and administration of vasoactive agents such as terlipressin or octreotide. Prophylactic IV antibiotics are also recommended to reduce mortality in patients with liver cirrhosis. Endoscopic variceal band ligation is the preferred method for controlling bleeding, and the use of a Sengstaken-Blakemore tube or Transjugular Intrahepatic Portosystemic Shunt (TIPSS) may be necessary if bleeding cannot be controlled. However, TIPSS can lead to exacerbation of hepatic encephalopathy, which is a common complication.

To prevent variceal haemorrhage, prophylactic measures such as propranolol and endoscopic variceal band ligation (EVL) are recommended. Propranolol has been shown to reduce rebleeding and mortality compared to placebo. EVL is superior to endoscopic sclerotherapy and should be performed at two-weekly intervals until all varices have been eradicated. Proton pump inhibitor cover is given to prevent EVL-induced ulceration. NICE guidelines recommend offering endoscopic variceal band ligation for the primary prevention of bleeding for people with cirrhosis who have medium to large oesophageal varices.

The use of macrolides, such as erythromycin and clarithromycin, has been associated with QT interval prolongation. Other antimicrobials like fluoroquinolones (e.g. ciprofloxacin) and oral antifungals (e.g. fluconazole, ketoconazole) have also been implicated. Additionally, certain medications used for arrhythmias (e.g. amiodarone), psychiatric disorders (e.g. haloperidol), and depression (e.g. citalopram) can cause QT prolongation. However, doxycycline, propranolol, levothyroxine, and ibuprofen are not known to have this effect.

Macrolides are a class of antibiotics that include erythromycin, clarithromycin, and azithromycin. They work by blocking translocation during bacterial protein synthesis, ultimately inhibiting bacterial growth. While they are generally considered bacteriostatic, their effectiveness can vary depending on the dose and type of organism being treated. Resistance to macrolides can occur through post-transcriptional methylation of the 23S bacterial ribosomal RNA.

However, macrolides can also have adverse effects. They may cause prolongation of the QT interval and gastrointestinal side-effects, such as nausea. Cholestatic jaundice is a potential risk, but using erythromycin stearate may reduce this risk. Additionally, macrolides are known to inhibit the cytochrome P450 isoenzyme CYP3A4, which metabolizes statins. Therefore, it is important to stop taking statins while on a course of macrolides to avoid the risk of myopathy and rhabdomyolysis. Azithromycin is also associated with hearing loss and tinnitus.

Overall, while macrolides can be effective antibiotics, they do come with potential risks and side-effects. It is important to weigh the benefits and risks before starting a course of treatment with these antibiotics.

Horner’s syndrome is a condition characterized by several features, including a small pupil (miosis), drooping of the upper eyelid (ptosis), a sunken eye (enophthalmos), and loss of sweating on one side of the face (anhidrosis). The cause of Horner’s syndrome can be determined by examining additional symptoms. For example, congenital Horner’s syndrome may be identified by a difference in iris color (heterochromia), while anhidrosis may be present in central or preganglionic lesions. Pharmacologic tests, such as the use of apraclonidine drops, can also be helpful in confirming the diagnosis and identifying the location of the lesion. Central lesions may be caused by conditions such as stroke or multiple sclerosis, while post-ganglionic lesions may be due to factors like carotid artery dissection or cluster headaches. It is important to note that the appearance of enophthalmos in Horner’s syndrome is actually due to a narrow palpebral aperture rather than true enophthalmos.

NSAIDS should be the first choice for treating lower back pain. Codeine, which is part of the opioid pain ladder, should not be used for managing nonspecific lower back pain as it can lead to dependence and dose escalation. Additionally, administering codeine via IM is only recommended for patients who cannot tolerate oral medication, which is not applicable in this case. Therefore, oral codeine should not be considered as a primary treatment option for nonspecific lower back pain.

Management of Lower Back Pain: NICE Guidelines

Lower back pain is a common condition that affects many people. In 2016, the National Institute for Health and Care Excellence (NICE) updated their guidelines on the management of lower back pain. These guidelines apply to patients with nonspecific lower back pain, which means it is not caused by malignancy, infection, trauma, or other specific conditions.

According to the updated guidelines, NSAIDs are now recommended as the first-line treatment for back pain. Paracetamol monotherapy is relatively ineffective for back pain, so NSAIDs are a better option. Proton pump inhibitors should be co-prescribed for patients over the age of 45 years who are given NSAIDs.

Lumbar spine x-ray should not be offered as an investigation for nonspecific back pain. MRI should only be offered to patients with nonspecific back pain if the result is likely to change management, or if malignancy, infection, fracture, cauda equina, or ankylosing spondylitis is suspected. MRI is the most useful imaging modality as it can see neurological and soft tissue structures.

Patients with low back pain should be encouraged to self-manage and stay physically active through exercise. A group exercise program within the NHS is recommended for people with back pain. Manual therapy, such as spinal manipulation, mobilization, or soft tissue techniques like massage, can be considered as part of a treatment package that includes exercise and psychological therapy. Radiofrequency denervation and epidural injections of local anesthetic and steroid can also be used for acute and severe sciatica.

In summary, the updated NICE guidelines recommend NSAIDs as the first-line treatment for nonspecific back pain. Patients should be encouraged to self-manage and stay physically active through exercise. MRI is the most useful imaging modality for investigating nonspecific back pain. Other treatments, such as manual therapy, radiofrequency denervation, and epidural injections, can be considered as part of a treatment package that includes exercise and psychological therapy.

Starting from 2017, the hepatitis B vaccination has been incorporated into the standard immunisation schedule in the UK, which now includes the 6-in-1 vaccine. Previously, the 5-in-1 vaccine comprised diphtheria, tetanus, pertussis, polio and haemophilus influenza type b. The hepatitis B vaccine is now administered alongside these at 8, 12 and 16 weeks after birth.

The UK immunisation schedule recommends certain vaccines at different ages. At birth, the BCG vaccine is given if the baby is at risk of tuberculosis. At 2, 3, and 4 months, the ‘6-1 vaccine’ (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B) and oral rotavirus vaccine are given, along with Men B and PCV at specific intervals. At 12-13 months, the Hib/Men C, MMR, PCV, and Men B vaccines are given. At 3-4 years, the ‘4-in-1 Preschool booster’ (diphtheria, tetanus, whooping cough and polio) and MMR vaccines are given. At 12-13 years, the HPV vaccination is given, and at 13-18 years, the ‘3-in-1 teenage booster’ (tetanus, diphtheria and polio) and Men ACWY vaccines are given. Additionally, the flu vaccine is recommended annually for children aged 2-8 years.

It is important to note that the meningitis ACWY vaccine has replaced meningitis C for 13-18 year-olds due to an increased incidence of meningitis W disease in recent years. The ACWY vaccine is also offered to new students up to the age of 25 years at university. GP practices will automatically send letters inviting 17-and 18-year-olds in school year 13 to have the Men ACWY vaccine, while students going to university or college for the first time should contact their GP to have the vaccine before the start of the academic year.

The Men C vaccine used to be given at 3 months but has now been discontinued as there are almost no cases of Men C disease in babies or young children in the UK. All children will continue to be offered the Hib/Men C vaccine at one year of age, and the Men ACWY vaccine at 14 years of age to provide protection across all age groups.

Hypercalcaemia in Palliative Care Patients

Hypercalcaemia is a common life-threatening metabolic disorder in cancer patients, particularly in those with myeloma and breast, renal, lung, and thyroid cancers. The severity of symptoms doesn’t always correlate with the degree of hypercalcaemia but often reflects the rapidity of onset. In palliative care patients, hypercalcaemia is a medical emergency that requires immediate attention.

Intravenous fluid replacement and intravenous bisphosphonates are the treatments of choice for hypercalcaemia in patients with a reasonable short-term prognosis who are willing to undergo treatment. It is important to note that hypercalcaemia can result from renal failure, so a urea level test may be useful. However, isolated acute kidney injury doesn’t explain the symptoms and may lead to a missed diagnosis.

A high serum alkaline phosphatase level is usually present in patients with bony metastases, but it would not be the most useful test in isolation. Although anaemia may be present in some patients, it doesn’t fit with the acute clinical symptoms, and a haemoglobin level test would not provide useful diagnostic information.

Thirst and polyuria may suggest diabetes, but the clinical history makes hypercalcaemia a more likely diagnosis. Therefore, it is crucial to consider hypercalcaemia as a potential cause of acute symptoms in palliative care patients.

Wilms’ Tumour: A Common Childhood Malignancy

Wilms’ tumour, also known as nephroblastoma, is a prevalent type of cancer in children, with a median age of diagnosis at 3 years old. It is often associated with Beckwith-Wiedemann syndrome, hemihypertrophy, and a loss-of-function mutation in the WT1 gene on chromosome 11. The most common presenting feature is an abdominal mass, which is usually painless, but other symptoms such as haematuria, flank pain, anorexia, and fever may also occur. In 95% of cases, the tumour is unilateral, and metastases are found in 20% of patients, most commonly in the lungs.

If a child presents with an unexplained enlarged abdominal mass, it is crucial to arrange a paediatric review within 48 hours to rule out Wilms’ tumour. The management of this cancer typically involves nephrectomy, chemotherapy, and radiotherapy if the disease is advanced. Fortunately, the prognosis for Wilms’ tumour is good, with an 80% cure rate.

Histologically, Wilms’ tumour is characterized by epithelial tubules, areas of necrosis, immature glomerular structures, stroma with spindle cells, and small cell blastomatous tissues resembling the metanephric blastema. Overall, early detection and prompt treatment are essential for a successful outcome in children with Wilms’ tumour.

Fit notes are limited to a maximum of 3 months per form during the initial issuance.

The eMed Initiative: Electronic Fit Notes

The eMed initiative is a project by the Department for Work and Pensions (DWP) aimed at replacing handwritten fit notes with electronically printed ones. This new system will be integrated into existing electronic record systems, such as EMIS, and stored alongside the patient’s record. The printed note will be given to the patient, who will use it in the same way as a handwritten note.

It is important to note that the electronic fit note will not be sent electronically to the employer, patient, or DWP. However, the DWP plans to collect anonymous data on sick notes in the future to inform policy development.

Despite the introduction of the eMed initiative, GPs will still be able to issue handwritten notes during home visits. Hospital doctors will also not be switching to the new system. The eMed initiative is a step towards modernizing the healthcare system and improving efficiency in the issuance of fit notes.

Primary biliary cholangitis is a chronic liver disorder that affects middle-aged women. It is thought to be an autoimmune condition that damages interlobular bile ducts, causing progressive cholestasis and potentially leading to cirrhosis. The classic presentation is itching in a middle-aged woman. It is associated with Sjogren’s syndrome, rheumatoid arthritis, systemic sclerosis, and thyroid disease. Diagnosis involves immunology and imaging tests. Management includes ursodeoxycholic acid, cholestyramine for pruritus, and liver transplantation in severe cases. Complications include cirrhosis, osteomalacia and osteoporosis, and an increased risk of hepatocellular carcinoma.

Vaccinations: Types and Precautions

Vaccinations are an important aspect of preventive healthcare. However, it is crucial to be aware of the different types of vaccines and their potential risks, especially for immunocompromised individuals. Live-attenuated vaccines, such as BCG, MMR, and oral polio, may pose a risk to these patients. In contrast, inactivated preparations, such as rabies and hepatitis A, and toxoid vaccines, such as tetanus and diphtheria, are safer options. Subunit and conjugate vaccines, which use only part of the pathogen or link bacterial polysaccharide outer coats to proteins, respectively, are also available for diseases like pneumococcus, haemophilus, meningococcus, hepatitis B, and human papillomavirus.

It is important to note that different types of influenza vaccines are available, including whole inactivated virus, split virion, and sub-unit. Additionally, the cholera vaccine contains inactivated strains of Vibrio cholerae and the recombinant B-subunit of the cholera toxin. The hepatitis B vaccine is prepared from yeast cells using recombinant DNA technology and contains HBsAg adsorbed onto an aluminum hydroxide adjuvant.

In summary, vaccinations are an essential tool in preventing the spread of infectious diseases. However, it is crucial to understand the different types of vaccines and their potential risks to make informed decisions about vaccination.