First Aid and Management of Burns

Burns can be caused by heat, electricity, or chemicals. Immediate first aid involves removing the person from the source of the burn and irrigating the affected area with cool water. The extent of the burn can be assessed using Wallace’s Rule of Nines or the Lund and Browder chart. The depth of the burn can be determined by its appearance, with full-thickness burns being the most severe. Referral to secondary care is necessary for deep dermal and full-thickness burns, as well as burns involving certain areas of the body or suspicion of non-accidental injury.

Severe burns can lead to tissue loss, fluid loss, and a catabolic response. Intravenous fluids and analgesia are necessary for resuscitation and pain relief. Smoke inhalation can result in airway edema, and early intubation may be necessary. Circumferential burns may require escharotomy to relieve compartment syndrome and improve ventilation. Conservative management is appropriate for superficial burns, while more complex burns may require excision and skin grafting. There is no evidence to support the use of antimicrobial prophylaxis or topical antibiotics in burn patients.

Trigeminal Neuralgia: A Debilitating Condition Resulting in Intense Pain

Trigeminal neuralgia is a chronic condition that causes extreme episodes of pain in the cheek and lower jaw. These episodes are sudden and sporadic, often described as electric shocks that can last from a few seconds to several minutes. While the episodes themselves are intermittent, they can recur for days, weeks, or even months before disappearing for extended periods. Some patients may experience bilateral pains. Triggers for these episodes include brushing teeth, eating and drinking, exposure to wind, skin contact (such as shaving or washing), and vibration.

Diagnosis is typically clinical, and no investigations are necessary unless there is uncertainty. Carbamazepine is the most effective treatment and should be tried initially, with the dose titrated up to achieve pain control, usually to about 200 mg three or four times a day (maximum 1600mg per day). Once in remission, the dose should be gradually reduced and discontinued until further attacks occur.

If carbamazepine is ineffective, the patient should be referred to a specialist. Normal analgesics are ineffective, and while gabapentin, clonazepam, baclofen, lamotrigine, and amitriptyline have been used, adequate evidence supporting their use is lacking. Abnormal clinical features, such as burning pain between paroxysms, loss of sensation, or any abnormal neurological signs, should also prompt referral.

Polymyalgia Rheumatica: A Condition Common in the Elderly

Polymyalgia rheumatica is a condition that typically affects individuals over the age of 50, with the highest incidence in those over 70 years old. One of the core features of PMR is age greater than 50. The most common symptoms of PMR include bilateral shoulder and/or pelvic girdle aching that lasts for more than two weeks, morning stiffness lasting for more than 45 minutes, and raised erythrocyte sedimentation rate (ESR) and C reactive protein (CRP). It is important to note that these symptoms can also be present in other conditions, so a proper diagnosis is necessary.

Zoon’s balanitis is a benign condition affecting uncircumcised men, presenting with orange-red lesions with pinpoint redder spots on the glans and adjacent areas of the foreskin. It may be secondary to other conditions such as lichen sclerosus or erythroplasia of Queyrat. Differential diagnoses include lichen sclerosus, seborrhoeic dermatitis, and psoriasis.

Understanding Zoon’s Balanitis

Zoon’s balanitis, also known as plasma cell balanitis, is a chronic condition that affects the head of the penis. It is commonly seen in middle-aged or elderly men who are not circumcised. The condition is characterized by erythematous, well-defined, and shiny patches that appear on the head of the penis.

Although Zoon’s balanitis is generally benign, a biopsy may be necessary to rule out other possible diagnoses. Circumcision is often the most effective treatment for this condition. However, carbon dioxide laser therapy and topical corticosteroids may also be used to manage the symptoms.

In summary, Zoon’s balanitis is a chronic condition that affects the head of the penis. It is typically seen in older men who are not circumcised. While circumcision is the most effective treatment, other options such as laser therapy and topical corticosteroids may also be used.

Isotretinoin can cause various adverse effects, including teratogenicity, which requires females to take contraception. Other side effects may include low mood, dry eyes and lips, raised triglycerides, hair thinning, and nosebleeds. However, hypertension is not listed as a side effect in the British National Formulary.

Understanding Isotretinoin and its Adverse Effects

Isotretinoin is a type of oral retinoid that is commonly used to treat severe acne. It has been found to be effective in providing long-term remission or cure for two-thirds of patients who undergo a course of treatment. However, it is important to note that isotretinoin also comes with several adverse effects that patients should be aware of.

One of the most significant adverse effects of isotretinoin is its teratogenicity, which means that it can cause birth defects in fetuses if taken during pregnancy. For this reason, females who are taking isotretinoin should ideally be using two forms of contraception to prevent pregnancy. Other common adverse effects of isotretinoin include dry skin, eyes, and lips/mouth, low mood, raised triglycerides, hair thinning, nosebleeds, and photosensitivity.

It is also worth noting that there is some controversy surrounding the potential link between isotretinoin and depression or other psychiatric problems. While these adverse effects are listed in the British National Formulary (BNF), further research is needed to fully understand the relationship between isotretinoin and mental health.

Overall, while isotretinoin can be an effective treatment for severe acne, patients should be aware of its potential adverse effects and discuss any concerns with their healthcare provider.

In most cases, labial adhesion can be resolved through conservative methods. However, if the individual experiences symptoms such as pain, difficulty urinating, or dribbling, it is recommended to apply oestrogen cream for a period of 6 weeks until the membrane dissolves. Following this, an emollient should be applied for a duration of 2 months.

Labial Adhesions: Causes, Symptoms, and Treatment

Labial adhesions refer to the fusion of the labia minora in the middle, which is commonly observed in girls aged between 3 months and 3 years. This condition can be treated conservatively, and spontaneous resolution usually occurs around puberty. It is important to note that labial adhesions are different from an imperforate hymen.

Symptoms of labial adhesions include problems with urination, such as pooling in the vagina. Upon examination, thin semitranslucent adhesions covering the vaginal opening between the labia minora may be seen, which can sometimes cover the vaginal opening completely.

Conservative management is usually appropriate for most cases of labial adhesions. However, if there are associated problems such as recurrent urinary tract infections, oestrogen cream may be tried. If this fails, surgical intervention may be necessary.

In summary, labial adhesions are a common condition in young girls that can cause problems with urination. While conservative management is usually effective, medical intervention may be necessary in some cases.

During intercurrent illness such as diarrhoea and vomiting, it is important to suspend the use of metformin as it increases the risk of lactic acidosis. Increasing the dose of ramipril is not recommended as it may increase the risk of electrolyte disturbance while the patient is unwell. Similarly, there is no indication to double the dose of lansoprazole. Suspending ramipril is also not necessary as there is no evidence of acute electrolyte disturbance. However, reducing the dose of paracetamol to 500mg may be considered for patients with a low body weight.

The following table provides a summary of the typical side-effects associated with drugs used to treat diabetes mellitus. Metformin is known to cause gastrointestinal side-effects and lactic acidosis. Sulfonylureas can lead to hypoglycaemic episodes, increased appetite and weight gain, as well as the syndrome of inappropriate ADH secretion and cholestatic liver dysfunction. Glitazones are associated with weight gain, fluid retention, liver dysfunction, and fractures. Finally, gliptins have been linked to pancreatitis.

Dosage Calculation Errors

Dosage calculation errors can have serious consequences for patients. Here are some examples of errors and how to correct them:

1. 45 mg/24 hours, 7.5 mg for breakthrough pain
To calculate the 24 hour dose, add together the current doses in 24 hours and convert to an equivalent subcutaneous dose. For morphine, divide by 2. The breakthrough dose is 1/6 of the baseline dose.

2. 45 mg/24 hours, 10 mg for breakthrough pain
The baseline dose over 24 hours is correct but the breakthrough dose is incorrect. The dose for breakthrough pain is 1/6 of the baseline dose.

3. 60 mg/24 hours, 10 mg for breakthrough pain
The 24 hour dose needs to incorporate PRN doses and be adjusted for administration by injection rather than oral.

4. 90 mg/24 hours, 15 mg for breakthrough pain
The error made here is not converting the dose from oral to subcutaneous. This is done by dividing the oral dose by 2.

5. 30 mg/24 hours, 5 mg for breakthrough pain
The baseline dose needs to include any PRN doses taken. The current regimen should be converted from oral to subcutaneous correctly, but the 30 mg of oral solution taken should also be taken into account.

Treatment Options for Otitis Media with Effusion in Children

Otitis media with effusion is a common condition in children, but it is usually self-limiting and resolves within 12 months. While there is no proven benefit from medication, there are several treatment options available.

Observation is a viable option, as a period of watchful waiting is unlikely to result in any long-term complications. However, if signs and symptoms persist, referral for a hearing test after 6-12 weeks or to a specialist in ear, nose, and throat (ENT) may be necessary.

Antibiotics are not indicated in cases where there are no symptoms or signs of active infection. Intranasal corticosteroids and oral antihistamines are also not recommended by The National Institute for Health and Care Excellence (NICE) for the treatment of otitis media with effusion in children.

Nasal decongestants, such as pseudoephedrine, may provide temporary relief for stuffy nose and sinus pain/pressure caused by infection or other breathing illnesses, but they are not indicated for children with glue ear.

In summary, the best course of action for otitis media with effusion in children is often observation, with referral to a specialist if necessary. Other treatment options should be carefully considered and discussed with a healthcare provider.

Pelvic floor muscle training is the most effective and cost-efficient treatment for stress urinary incontinence in women. Ring pessaries are an alternative non-surgical option for pelvic organ prolapse. Oxybutynin is typically used for urge incontinence, but in this scenario, the patient only presents with stress incontinence. While a referral to urogynaecology may be considered for further investigation or surgery, it is not necessary under the 2-week-wait pathway. Pelvic floor exercises should be attempted for at least 3 months under the guidance of a continence adviser, specialist nurse, or women’s health physiotherapist. As the patient’s symptoms persist after 6 months of trying this approach, it is not advisable to continue with the same strategy.

Urinary incontinence is a common condition that affects approximately 4-5% of the population, with elderly females being more susceptible. There are several risk factors that can contribute to the development of urinary incontinence, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. The condition can be classified into different types, such as overactive bladder, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

Initial investigation of urinary incontinence involves completing bladder diaries for at least three days, performing a vaginal examination to exclude pelvic organ prolapse, and conducting urine dipstick and culture tests. Urodynamic studies may also be necessary. Management of urinary incontinence depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures may be necessary. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be offered to women who decline surgical procedures.

In summary, urinary incontinence is a common condition that can be caused by various risk factors. It can be classified into different types, and management depends on the predominant type of incontinence. Initial investigation involves completing bladder diaries, performing a vaginal examination, and conducting urine tests. Treatment options include bladder retraining, bladder stabilizing drugs, pelvic floor muscle training, surgical procedures, and duloxetine.

Specialist spinal services (neurosurgery or orthopaedic spinal surgery) should urgently assess all patients with degenerative cervical myelopathy due to the importance of early treatment. The timing of surgery is crucial as any existing spinal cord damage can be permanent. Early treatment, within 6 months of diagnosis, offers the best chance of a full recovery. However, most patients are presenting too late, with an average of over 5 appointments before diagnosis, representing more than 2 years in one study.

Decompressive surgery is currently the only effective treatment that has been shown to prevent disease progression. Close observation is an option for mild stable disease, but anything progressive or severe requires surgery to prevent further deterioration. Physiotherapy should only be initiated by specialist services as manipulation can cause more spinal cord damage.

To ensure good outcomes for patients, prompt diagnosis and onward referral are crucial. National initiatives are underway to raise awareness of the condition and improve referral times. None of the other listed options in this question control the patient’s primary pathology.

Degenerative cervical myelopathy (DCM) is a condition that has several risk factors, including smoking, genetics, and certain occupations that expose individuals to high axial loading. The symptoms of DCM can vary in severity and may include pain, loss of motor function, loss of sensory function, and loss of autonomic function. Early symptoms may be subtle and difficult to detect, but as the condition progresses, symptoms may worsen or new symptoms may appear. An MRI of the cervical spine is the gold standard test for diagnosing cervical myelopathy. All patients with DCM should be urgently referred to specialist spinal services for assessment and treatment. Decompressive surgery is currently the only effective treatment for DCM, and early treatment offers the best chance of a full recovery. Physiotherapy should only be initiated by specialist services to prevent further spinal cord damage.

Referral Pathways for Children with Developmental Delays

When a child presents with developmental delays, it is important to consider appropriate referral pathways to ensure they receive the necessary assessments and interventions. Here are some examples of referral pathways for children with specific concerns:

Refer to Audiology: If a child is presenting with speech delay and suspected hearing loss, they should be referred to Audiology for assessment.

Refer to Paediatrics: For children with delays in one area of development or more general concerns, a full developmental assessment with a Paediatrician may be necessary. However, for isolated concerns regarding hearing and speech, an audiology assessment can be a useful initial investigation.

Refer to Physiotherapy: Children presenting with delays in gross motor development may benefit from a referral to Physiotherapy.

Refer to Social Services: While there may be no safeguarding concerns identified, it is important to remain vigilant about safeguarding concerns in children presenting with developmental delays.

Refer to the Health Visitor: The Health Visitor can provide support to parents and caregivers, but if there are concerns regarding hearing and speech delays, a referral to Audiology should be made for assessment.

Cyclizine is a recommended first-line anti-emetic for nausea and vomiting caused by intracranial or intra-vestibular issues, as well as for managing gastrointestinal obstruction in palliative care. Domperidone is effective for gastro-intestinal pain in palliative care, as it stimulates gastric muscle contraction by blocking dopamine inhibition. Metoclopramide is useful for acute migraine, chemotherapy or radiotherapy-induced nausea and vomiting, but is unlikely to relieve nausea related to increased intracranial pressure. Ondansetron is indicated for preventing and treating chemotherapy-related nausea and vomiting. Dexamethasone is often the first choice steroid in palliative care, as it can treat multiple symptoms including nausea, anorexia, spinal cord compression, and liver capsule pain. If the patient’s nausea is due to raised intracranial pressure, cyclizine should be the first-line option, but dexamethasone may also be considered as an additional treatment.

Nausea and Vomiting in Palliative Care: Mechanistic Approach to Prescribing

Nausea and vomiting in palliative care can have multiple causes, but identifying the most prominent one is crucial in guiding the choice of anti-emetic therapy. Six broad syndromes have been identified, with gastric stasis and chemical disturbance being the most common. In general, pharmacological therapy is the first-line method for treating nausea and vomiting in palliative care. There are two approaches to choosing drug therapy: empirical and mechanistic. The mechanistic approach matches the choice of anti-emetic drug to the likely cause of the patient’s nausea and vomiting.

For reduced gastric motility, pro-kinetic agents such as metoclopramide and domperidone are useful. However, metoclopramide should not be used when pro-kinesis may negatively affect the gastrointestinal tract. For chemically mediated nausea and vomiting, the chemical disturbance should be corrected first. Key treatment options include ondansetron, haloperidol, and levomepromazine. Cyclizine and levomepromazine are first-line for visceral/serosal causes, while anticholinergics such as hyoscine can be useful. For raised Intracranial pressure, cyclizine and dexamethasone are recommended. For vestibular causes, cyclizine is the first-line treatment, while atypical antipsychotics such as olanzapine or risperidone can be used in refractory cases. If anticipatory nausea is the clear cause, a short-acting benzodiazepine such as lorazepam can be useful.

NICE CKS recommends that oral anti-emetics are preferable and should be used if possible. If the oral route is not possible, the parenteral route of administration is preferred. The intravenous route can be used if intravenous access is already established. By using a mechanistic approach to prescribing, healthcare professionals can tailor anti-emetic therapy to the specific cause of nausea and vomiting in palliative care patients.

Mumps: Symptoms, Complications, and Incubation Period

Mumps is a viral infection that has an incubation period of 14-21 days. The patient typically experiences a nonspecific prodrome of sore throat, fever, malaise, and headache, which eventually leads to inflammation of the parotid gland. Fortunately, symptomatic treatment is usually sufficient, and the illness resolves within one to two weeks.

However, mumps can lead to serious complications, with meningoencephalitis occurring in 10% of patients with parotitis, and orchitis occurring in 25% of postpubertal males affected by mumps. In about 15% of those affected by orchitis, it is bilateral.

It’s worth noting that the incubation period for mumps may vary slightly depending on the reference source. However, the correct answer should always fall within a reasonable range, so don’t be too concerned if the limits of the reference range differ slightly from what you may have read elsewhere.

Facial Paralysis: Understanding the Causes and Symptoms

Facial paralysis can be caused by a variety of factors, including stroke, brain tumours, and viral infections. The most common type of facial paralysis is Bell’s palsy, which is often idiopathic in nature. In Bell’s palsy, the brow is paralyzed due to a lower motor neuron facial nerve palsy. While the underlying cause is often unknown, viruses such as herpes simplex type 1 have been implicated. Other potential causes include mononeuropathy in diabetes or sarcoid, Lyme disease, and posterior fossa tumours.

Fortunately, the majority of patients with Bell’s palsy recover significantly within six weeks to three months, with around 70% making a full recovery. Treatment typically involves prednisolone and vigilant eye care.

It’s important to differentiate Bell’s palsy from other potential causes of facial paralysis, such as stroke or brain tumours. In a stroke, the brow would not be paralyzed due to an upper motor neuron lesion. While a posterior fossa tumour can cause facial palsy, it is less common than Bell’s palsy. Paralysis is a nonspecific diagnosis and not the best answer, while Ramsay Hunt syndrome is associated with the varicella-zoster virus and typically presents with concomitant shingles, which is not present in this patient.

Possible Causes of Poor Urinary Stream in Boys

Poor urinary stream in boys can be a sign of urinary-tract obstruction, which is often caused by posterior urethral valves. While this condition is usually diagnosed before birth, delayed presentation can be due to recurrent urinary tract infections. Other possible causes of poor urinary stream include urethral stricture, bladder calculi, and neurogenic bladder. However, these conditions are less common and may be associated with other developmental or neurological issues. Vesicoureteric reflux, which occurs when urine flows back from the bladder up the ureters, may also be a result of urinary tract obstruction but is not likely to be the primary cause of poor urinary stream and terminal dribbling.

Patients who have developed rhinophyma as a result of rosacea should be referred to a dermatologist for further evaluation and treatment. Rhinophyma is a severe form of rosacea that affects the nasal soft tissues, causing nasal obstruction, disfigurement, and significant psychological distress. Only specialized care in secondary settings can provide the necessary assessment and management, which may include laser therapy, scalpel excision, electrocautery, or surgery.

Continuing with self-management measures is not recommended as the patient requires an escalation in treatment. However, lifestyle modifications remain an essential aspect of her management.

Prescribing oral doxycycline is not appropriate in this case as the patient is pregnant, and the medication is contraindicated.

Topical brimonidine is also not recommended as the manufacturer advises against its use during pregnancy due to limited information available. While it can provide temporary relief of flushing and erythema symptoms, it is not a suitable treatment option for rhinophyma.

Rosacea, also known as acne rosacea, is a skin condition that is chronic in nature and its cause is unknown. It typically affects the nose, cheeks, and forehead, and the first symptom is often flushing. Telangiectasia, which are small blood vessels that are visible on the skin, are common, and the condition can progress to persistent erythema with papules and pustules. Rhinophyma, a condition where the nose becomes enlarged and bulbous, can also occur. Ocular involvement, such as blepharitis, can also be present, and sunlight can exacerbate symptoms.

Management of rosacea depends on the severity of the symptoms. For mild symptoms, topical metronidazole may be used, while topical brimonidine gel may be considered for patients with predominant flushing but limited telangiectasia. More severe cases may require systemic antibiotics such as oxytetracycline. It is recommended that patients apply a high-factor sunscreen daily and use camouflage creams to conceal redness. Laser therapy may be appropriate for patients with prominent telangiectasia, and those with rhinophyma should be referred to a dermatologist for further management.

Anticoagulation should be started despite the risk of falls or old age alone, according to NICE guidelines. Previously, doctors would consider factors such as alcohol abuse when deciding whether to start anticoagulation due to the risk of haemorrhage. However, the ORBIT score is now recommended by NICE to determine the risk of haemorrhage. Delaying or withholding anticoagulation could be dangerous for the patient while they are at risk of stroke. Aspirin is no longer used for thromboembolism prophylaxis in atrial fibrillation, so both answers involving aspirin are incorrect.

Atrial fibrillation (AF) is a condition that requires careful management, including the use of anticoagulation therapy. The latest guidelines from NICE recommend assessing the need for anticoagulation in all patients with a history of AF, regardless of whether they are currently experiencing symptoms. The CHA2DS2-VASc scoring system is used to determine the most appropriate anticoagulation strategy, with a score of 2 or more indicating the need for anticoagulation. However, it is important to ensure a transthoracic echocardiogram has been done to exclude valvular heart disease, which is an absolute indication for anticoagulation.

When considering anticoagulation therapy, doctors must also assess the patient’s bleeding risk. NICE recommends using the ORBIT scoring system to formalize this risk assessment, taking into account factors such as haemoglobin levels, age, bleeding history, renal impairment, and treatment with antiplatelet agents. While there are no formal rules on how to act on the ORBIT score, individual patient factors should be considered. The risk of bleeding increases with a higher ORBIT score, with a score of 4-7 indicating a high risk of bleeding.

For many years, warfarin was the anticoagulant of choice for AF. However, the development of direct oral anticoagulants (DOACs) has changed this. DOACs have the advantage of not requiring regular blood tests to check the INR and are now recommended as the first-line anticoagulant for patients with AF. The recommended DOACs for reducing stroke risk in AF are apixaban, dabigatran, edoxaban, and rivaroxaban. Warfarin is now used second-line, in patients where a DOAC is contraindicated or not tolerated. Aspirin is not recommended for reducing stroke risk in patients with AF.

Proper Use of Anonymised Patient Record Data from Primary Care

The General Practice Research Database (GPRD) is a valuable resource for conducting epidemiological studies. However, it is important to use the dataset properly to avoid biased results. For instance, comparing patients taking a drug with those not taking the drug may lead to biased conclusions, as patients with certain conditions may be more likely to take the drug. In the case of chronic obstructive pulmonary disease (COAD), which is associated with smoking and increased cardiovascular mortality, an appropriate strategy would be to compare matched controls with COAD who do not use inhalers with those who do. This approach can help reduce inclusion bias, which is a common issue in observational studies that use patient record data. By using the GPRD appropriately, researchers can obtain reliable and informative insights into various health conditions and treatments.

Retinal Detachment: Causes, Symptoms, and Treatment

Retinal detachment is a serious condition that can lead to permanent vision loss if left untreated. It occurs when the retina, the thin layer of tissue at the back of the eye responsible for transmitting visual information to the brain, separates from its underlying support tissue. Here are some important facts about retinal detachment:

Causes: Retinal detachment can result from a variety of factors, including a posterior vitreous detachment, myopia, severe acute hypertension, inflammation, or neoplastic effusions.

Symptoms: Symptoms of retinal detachment include sudden onset of floaters, flashes of light, and a curtain-like shadow over the visual field. However, some patients may not experience any symptoms at all.

Treatment: Retinal tears and holes are treated with cryotherapy or laser photocoagulation. Most actual detachments require surgery to flatten the retina. Patients who do not have immediate surgery may have strict bedrest and to hold the head in a particular position to prevent progression of the detachment. The retina is successfully reattached in around 85% of cases. In cases where the macula is not involved, 90% of patients have 20/40 vision or better after reattachment surgery.

Understanding Retinal Detachment: Causes, Symptoms, and Treatment

Treatment Options for COPD Patients with Persistent Breathlessness

Here we have a patient with COPD who is persistently breathless despite regular use of a short acting beta agonist (SABA) and has an FEV1 of greater than 50%. In this case, add-on inhaled treatment is indicated. According to available guidelines and evidence, the options are to start a long acting beta agonist (LABA) or a long acting muscarinic antagonist (LAMA).

Of the options given, the addition of a LAMA is the correct answer, provided there are no asthmatic features or indicators of steroid responsiveness. If these features are present, then a combination of LABA and inhaled corticosteroid (ICS) would be considered. It is important to note that proper treatment options should be discussed with a healthcare professional.

Understanding the Risk of Hypoglycaemia with Sulfonylureas

Sulfonylureas are commonly used to treat type 2 diabetes, but they come with a risk of hypoglycaemia, which can be dangerous. This risk is greatest in patients with co-existing hepatic impairment, as the drugs are metabolised in the liver and excreted in urine or faeces. Short-acting sulfonylureas are not necessarily riskier than longer-acting ones, but they should be used with caution in patients with renal disease. Hypoglycaemia may persist for many hours and should be treated in the hospital. Excessive dosage is a common cause of hypoglycaemia, so careful monitoring is essential. Combining sulfonylureas with bedtime isophane insulin may be an option when other treatments fail, but it doesn’t reduce the risk of hypoglycaemia. Patients and healthcare providers should be aware of the risks associated with sulfonylureas and take steps to minimise them.

Understanding Anterior Cord Syndrome: Causes and Effects

Anterior cord syndrome occurs when the blood supply to the anterior portion of the spinal cord is interrupted. This portion of the spinal cord is supplied by the anterior spinal artery, which receives branches from the aorta. Therefore, lesions within the aorta, such as aneurysm or atherosclerosis, are the most common causes of anterior cord syndrome. Other causes include vasculitis, polycythemia, sickle cell disease, decompression sickness, cocaine use, and collagen and elastin disorders.

Anterior spinal artery thrombosis affects the corticospinal tracts and spinothalamic tracts, which are responsible for motor neurons and pain/temperature sensation. These tracts are located at the front of the spine. Posterior columns, which carry vibration and joint-position sense, are not affected. As a spinal lesion, anterior cord syndrome is purely upper motor neuronal, resulting in brisk reflexes and up-going plantars.

In contrast, other conditions that affect both upper and lower motor neurons will produce a combination of up-going plantars with absent knee jerks. Understanding the causes and effects of anterior cord syndrome can aid in diagnosis and treatment.

Treatment Options for Scalp Psoriasis: NICE Guidelines and Beyond

Scalp psoriasis is a common condition that can cause discomfort and embarrassment. One telltale sign is Auspitz’s sign, where pinpoint bleeding occurs when a scale is removed due to thinning of the epidermal layer overlying the dermal papillae. The National Institute for Health and Care Excellence (NICE) recommends using a potent corticosteroid as initial treatment for up to four weeks, followed by a different formulation or calcipotriol if necessary. Topical agents containing salicylic acid, emollients, or oils can also be used to remove scale before resuming corticosteroid treatment. However, tar-based shampoos are not recommended as a sole treatment option. A combined product containing calcipotriol and betamethasone dipropionate may be used as a first-line treatment, as it has been shown to be more effective than using the drugs separately. Overall, there are various treatment options available for scalp psoriasis, and it is important to consult with a healthcare professional to determine the best course of action.

Smoking Cessation Options for a Woman Trying to Conceive

Nicotine replacement therapy (NRT) is the recommended option for a woman trying to conceive who is struggling to quit smoking. While it is ideal for her to delay conception until she has successfully quit smoking and ceased NRT, the benefits of NRT outweigh the risks of smoking and NRT. It is important for her to also receive behavioral support through a Stop Smoking Service. E-cigarettes are not currently recommended due to lack of evidence on their safety and effectiveness. Bupropion and varenicline are contraindicated in pregnancy and should not be prescribed. While attending a Stop Smoking Service is preferred, medical treatments such as NRT can be prescribed in primary care.

When beta-blockers fail to control angina, it is recommended to supplement with a dihydropyridine calcium channel blocker that has a longer duration of action.

Angina pectoris can be managed through lifestyle changes, medication, percutaneous coronary intervention, and surgery. In 2011, NICE released guidelines for the management of stable angina. Medication is an important aspect of treatment, and all patients should receive aspirin and a statin unless there are contraindications. Sublingual glyceryl trinitrate can be used to abort angina attacks. NICE recommends using either a beta-blocker or a calcium channel blocker as first-line treatment, depending on the patient’s comorbidities, contraindications, and preferences. If a calcium channel blocker is used as monotherapy, a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker like amlodipine or modified-release nifedipine should be used. Beta-blockers should not be prescribed concurrently with verapamil due to the risk of complete heart block. If initial treatment is ineffective, medication should be increased to the maximum tolerated dose. If a patient is still symptomatic after monotherapy with a beta-blocker, a calcium channel blocker can be added, and vice versa. If a patient cannot tolerate the addition of a calcium channel blocker or a beta-blocker, long-acting nitrate, ivabradine, nicorandil, or ranolazine can be considered. If a patient is taking both a beta-blocker and a calcium-channel blocker, a third drug should only be added while awaiting assessment for PCI or CABG.

Nitrate tolerance is a common issue for patients who take nitrates, leading to reduced efficacy. NICE advises patients who take standard-release isosorbide mononitrate to use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimize the development of nitrate tolerance. However, this effect is not seen in patients who take once-daily modified-release isosorbide mononitrate.

The typical presentation of vestibular schwannoma involves a combination of symptoms such as vertigo, hearing loss, tinnitus, and an absent corneal reflex. On the other hand, the symptoms of acoustic neuroma may vary depending on the cranial nerve affected. In this case, the patient’s tinnitus and hearing loss suggest that the vestibulocochlear nerve is affected, and vertigo may also be present. Sensorineural hearing loss is observed in acoustic neuroma, whereas otosclerosis, impacted wax, and cholesteatoma cause conductive hearing loss. Meniere’s disease is characterized by progressive hearing loss that fluctuates in severity depending on the attacks.

Vestibular schwannomas, also known as acoustic neuromas, make up about 5% of intracranial tumors and 90% of cerebellopontine angle tumors. These tumors typically present with a combination of vertigo, hearing loss, tinnitus, and an absent corneal reflex. The specific symptoms can be predicted based on which cranial nerves are affected. For example, cranial nerve VIII involvement can cause vertigo, unilateral sensorineural hearing loss, and unilateral tinnitus. Bilateral vestibular schwannomas are associated with neurofibromatosis type 2.

If a vestibular schwannoma is suspected, it is important to refer the patient to an ear, nose, and throat specialist urgently. However, it is worth noting that these tumors are often benign and slow-growing, so observation may be appropriate initially. The diagnosis is typically confirmed with an MRI of the cerebellopontine angle, and audiometry is also important as most patients will have some degree of hearing loss. Treatment options include surgery, radiotherapy, or continued observation.

Genu valgum, commonly known as knock knees, is a typical condition that typically resolves on its own by the age of 8 years. As such, there is no need to refer the patient to an orthopaedic clinic or provide specific physiotherapy. Supportive shoes or leg braces are not recommended.

Common Variations in Lower Limb Development in Children

Parents may become concerned when they notice what appears to be abnormalities in their child’s lower limbs. This often leads to a visit to the primary care physician and a referral to a specialist. However, many of these variations are actually normal and will resolve on their own as the child grows.

One common variation is flat feet, where the medial arch is absent when the child is standing. This is typically seen in children of all ages and usually resolves between the ages of 4-8 years. Orthotics are not recommended, and parental reassurance is appropriate.

Another variation is in-toeing, which can be caused by metatarsus adductus, internal tibial torsion, or femoral anteversion. In most cases, these will resolve on their own, but severe or persistent cases may require intervention such as serial casting or surgical intervention. Out-toeing is also common in early infancy and usually resolves by the age of 2 years.

Bow legs, or genu varum, are typically seen in the first or second year of life and are characterized by an increased intercondylar distance. This variation usually resolves by the age of 4-5 years. Knock knees, or genu valgum, are seen in the third or fourth year of life and are characterized by an increased intermalleolar distance. This variation also typically resolves on its own.

In summary, many variations in lower limb development in children are normal and will resolve on their own. However, if there is concern or persistent symptoms, intervention may be appropriate.

NICE released updated guidelines in 2019 for the management of hypertension, building on previous guidelines from 2011. These guidelines recommend classifying hypertension into stages and using ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension. This is because some patients experience white coat hypertension, where their blood pressure rises in a clinical setting, leading to potential overdiagnosis of hypertension. ABPM and HBPM provide a more accurate assessment of a patient’s overall blood pressure and can help prevent overdiagnosis.

To diagnose hypertension, NICE recommends measuring blood pressure in both arms and repeating the measurements if there is a difference of more than 20 mmHg. If the difference remains, subsequent blood pressures should be recorded from the arm with the higher reading. NICE also recommends taking a second reading during the consultation if the first reading is above 140/90 mmHg. ABPM or HBPM should be offered to any patient with a blood pressure above this level.

If the blood pressure is above 180/120 mmHg, NICE recommends admitting the patient for specialist assessment if there are signs of retinal haemorrhage or papilloedema or life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure, or acute kidney injury. Referral is also recommended if a phaeochromocytoma is suspected. If none of these apply, urgent investigations for end-organ damage should be arranged. If target organ damage is identified, antihypertensive drug treatment may be started immediately. If no target organ damage is identified, clinic blood pressure measurement should be repeated within 7 days.

ABPM should involve at least 2 measurements per hour during the person’s usual waking hours, with the average value of at least 14 measurements used. If ABPM is not tolerated or declined, HBPM should be offered. For HBPM, two consecutive measurements need to be taken for each blood pressure recording, at least 1 minute apart and with the person seated. Blood pressure should be recorded twice daily, ideally in the morning and evening, for at least 4 days, ideally for 7 days. The measurements taken on the first day should be discarded, and the average value of all the remaining measurements used.

Interpreting the results, ABPM/HBPM above 135/85 mmHg (stage 1 hypertension) should be

The individual is suffering from thrush. Pregnancy prohibits the use of oral antifungal treatments, so a Clotrimazole pessary should be administered instead.

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.