In March 2018, NICE released new guidelines for identifying and managing Attention Deficit Hyperactivity Disorder (ADHD). This condition can have a significant impact on a child’s life and can continue into adulthood, making accurate diagnosis and treatment crucial. According to DSM-V, ADHD is characterized by persistent features of inattention and/or hyperactivity/impulsivity, with an element of developmental delay. Children up to the age of 16 must exhibit six of these features, while those aged 17 or over must exhibit five. ADHD has a UK prevalence of 2.4%, with a higher incidence in boys than girls, and there may be a genetic component.

NICE recommends a holistic approach to treating ADHD that is not solely reliant on medication. After presentation, a ten-week observation period should be implemented to determine if symptoms change or resolve. If symptoms persist, referral to secondary care is necessary, typically to a paediatrician with a special interest in behavioural disorders or to the local Child and Adolescent Mental Health Service (CAMHS). A tailored plan of action should be developed, taking into account the patient’s needs and wants, as well as how their condition affects their lives.

Drug therapy should be considered a last resort and is only available to those aged 5 years or older. Parents of children with mild/moderate symptoms can benefit from attending education and training programmes. For those who do not respond or have severe symptoms, pharmacotherapy may be considered. Methylphenidate is the first-line treatment for children and should be given on a six-week trial basis. It is a CNS stimulant that primarily acts as a dopamine/norepinephrine reuptake inhibitor. Side effects include abdominal pain, nausea, and dyspepsia. Weight and height should be monitored every six months in children. If there is an inadequate response, lisdexamfetamine should be considered, followed by dexamfetamine if necessary. In adults, methylphenidate or lisdexamfetamine are the first-line options, with switching between drugs if no benefit is seen after a trial of the other. All of these drugs are potentially cardiotoxic, so a baseline ECG should be performed before starting treatment, and referral to a cardiologist should be made if there is any significant past medical history or family history, or any doubt or ambiguity.

As with most psychiatric conditions, a thorough history and clinical examination are essential, particularly given the overlap of ADHD with many other psychiatric and

Shingles Vaccine Availability by Age

The shingles vaccine is available to individuals at different ages depending on their stage of life. Those who are 70 or 78-years old are eligible to receive the vaccine. However, it is not routinely offered to patients who are in their 50’s or 60’s. The vaccine is not part of the routine childhood immunisation schedule and is only available to NHS patients in their 70’s. It is not offered to individuals who are 80 or older, as it appears to be less effective in this age group. It is important to consult with a healthcare provider to determine the appropriate age to receive the shingles vaccine.

Understanding Prolapsed Disc and its Features

A prolapsed lumbar disc is a common cause of lower back pain that can lead to neurological deficits. It is characterized by clear dermatomal leg pain, which is usually worse than the back pain. The pain is often aggravated when sitting. The features of the prolapsed disc depend on the site of compression. For instance, L3 nerve root compression can cause sensory loss over the anterior thigh, weak quadriceps, reduced knee reflex, and a positive femoral stretch test. On the other hand, L4 nerve root compression can lead to sensory loss in the anterior aspect of the knee, weak quadriceps, reduced knee reflex, and a positive femoral stretch test.

The management of prolapsed disc is similar to that of other musculoskeletal lower back pain. It involves analgesia, physiotherapy, and exercises. According to NICE, the first-line treatment for back pain without sciatica symptoms is NSAIDs +/- proton pump inhibitors, rather than neuropathic analgesia. If the symptoms persist after 4-6 weeks, referral for consideration of MRI is appropriate. Understanding the features of prolapsed disc can help in the diagnosis and management of this condition.

Consider referral if the cyst remains after 12 weeks.

Ovarian enlargement is typically diagnosed through ultrasound imaging, which can determine whether the cyst is simple or complex. Simple cysts are unilocular and more likely to be benign, while complex cysts are multilocular and more likely to be malignant. Management of ovarian enlargement depends on the patient’s age and symptoms. Younger women may be treated conservatively if the cyst is small and simple, with a repeat ultrasound scheduled in 8-12 weeks. Postmenopausal women, however, should always be referred to a gynecologist for assessment, as physiological cysts are unlikely in this population. It’s important to note that ovarian cancer can present with vague symptoms, leading to delayed diagnosis.

The patient’s symptoms suggest optic neuritis, which is commonly caused by multiple sclerosis. This condition involves inflammation of the optic nerve, resulting in pain on movement, reduced visual acuity, and an RAPD due to reduced response to light in the affected eye. Multiple sclerosis is a demyelinating disease that can cause various symptoms, including optic neuritis, by damaging the myelin sheaths of nerves.

Rheumatoid arthritis is an autoimmune condition that primarily affects the joints but can also cause extra-articular manifestations throughout the body. In the eye, it tends to cause scleritis, episcleritis, and keratoconjunctivitis sicca, but not optic neuritis.

Behçet’s disease is another inflammatory disorder that affects multiple parts of the body, but its ocular manifestation is anterior uveitis, not optic neuritis.

Ulcerative colitis is an inflammatory bowel disease that involves inflammation of the lower GI tract. It can also cause extraintestinal manifestations, including scleritis and anterior uveitis in the eye.

Optic neuritis is a condition that can be caused by multiple sclerosis, diabetes, or syphilis. It is characterized by a decrease in visual acuity in one eye over a period of hours or days, as well as poor color discrimination and pain that worsens with eye movement. Other symptoms include a relative afferent pupillary defect and a central scotoma. The condition can be diagnosed through an MRI of the brain and orbits with gadolinium contrast. Treatment typically involves high-dose steroids, and recovery usually takes 4-6 weeks. If an MRI shows more than three white-matter lesions, the risk of developing multiple sclerosis within five years is approximately 50%.

It is now recommended to offer allopurinol to all patients after their first gout attack, without delay. However, it is advised to wait until the inflammation has subsided before discussing urate-lowering therapy with the patient. If the attacks are too frequent, allopurinol can be considered even before the inflammation has completely settled. These recommendations are provided by the 2017 British Society for Rheumatology and NICE Clinical Knowledge Summaries.

Gout is caused by chronic hyperuricaemia and is managed acutely with NSAIDs or colchicine. Urate-lowering therapy (ULT) is recommended for patients with >= 2 attacks in 12 months, tophi, renal disease, uric acid renal stones, or prophylaxis if on cytotoxics or diuretics. Allopurinol is first-line ULT, with an initial dose of 100 mg od and titrated to aim for a serum uric acid of < 300 µmol/l. Lifestyle modifications include reducing alcohol intake, losing weight if obese, and avoiding high-purine foods. Consideration should be given to stopping precipitating drugs and losartan may be suitable for patients with coexistent hypertension.

Endocrine Disorders: Addison’s Disease, Cushing Syndrome, and Conn Syndrome

Addison’s Disease:
Addison’s disease, or primary hypoadrenalism, is a condition characterized by chronic adrenal insufficiency. It is most commonly caused by autoimmune destruction of the adrenals in the UK, while tuberculosis is the most common cause worldwide. Other causes include long-term exogenous steroid use, cancer, or hemorrhage damage. Symptoms develop gradually, but patients can present in Addisonian crisis if there is a sudden deterioration in adrenal function or a physiological stress that the residual adrenal function cannot cope with. Treatment is with long-term replacement of corticosteroids and aldosterone.

Cushing Syndrome:
Cushing syndrome is a result of excess corticosteroid. It can be caused by exogenous steroids, primary hyperadrenalism, or secondary hyperadrenalism. Signs and symptoms include weight gain with moon facies and buffalo hump, hypertension, hyperglycemia, mood changes, hirsutism, baldness, and sleep disturbance.

Conn Syndrome:
Conn syndrome, also known as primary hyperaldosteronism, is caused most commonly by adrenal hyperplasia or adenomas. It results in excess aldosterone release, causing difficult-to-treat hypertension, hypernatremia, and hypokalemia.

Other Disorders:
Hypoglycemia occurs in insulinoma, but the other features are absent. Peutz-Jeghers syndrome is an autosomal dominant condition characterized by perioral freckling and small bowel polyps, which may present with vomiting secondary to intussusception from the small polyps but does not explain the hypoglycemia.

The Mechanism of Action of GTN in Angina Treatment

GTN is a prodrug that is denitrated to produce the active metabolite nitric oxide (NO). NO stimulates guanylate cyclase, which produces cGMP, leading to the relaxation of smooth muscle cells in blood vessels and dilatation of systemic veins. This reduces myocardial wall tension, increases oxygen transport to the subendocardium, and decreases the pressure of blood returning to the heart (preload). Additionally, NO activates calcium-regulated Na+/K+ ATPase pumps, reducing intracellular calcium levels and further relaxing muscle cells in the myocardium. Finally, widening of the large arteries reduces the pressure against which the heart has to pump (afterload), resulting in the heart needing less energy and oxygen. Overall, GTN’s mechanism of action in angina treatment involves reducing myocardial oxygen demand and increasing oxygen supply.

The initial and most important treatment for blepharitis, a common and chronic condition, is regular lid hygiene. Although there are different types of blepharitis, lid hygiene is the first-line treatment for all of them. The goal is to clear out any stagnant oily secretions, unblock meibomian glands, remove bacteria and flakes of skin, and soothe the eyelids. Patients should practice lid hygiene twice daily, which involves warmth, massage, and cleansing. There are many patient information leaflets available online that explain the process. Oral tetracycline is not the first-line treatment for blepharitis and is usually unnecessary if lid hygiene measures are followed. If symptoms persist, a course of oral tetracycline may be considered, especially in cases where meibomian gland dysfunction is prominent and there is associated rosacea. Sodium cromoglicate eye drops are not used in the management of blepharitis, as they are intended for allergic eye disease. Steroid eye drops are not a primary care treatment option for blepharitis and are not first-line, although they may be considered by specialists in cases resistant to other treatment measures.

Blepharitis is a condition where the eyelid margins become inflamed. This can be caused by dysfunction of the meibomian glands (posterior blepharitis) or seborrhoeic dermatitis/staphylococcal infection (anterior blepharitis). It is more common in patients with rosacea. The meibomian glands secrete oil to prevent rapid evaporation of the tear film, so any problem affecting these glands can cause dryness and irritation of the eyes. Symptoms of blepharitis are usually bilateral and include grittiness, discomfort around the eyelid margins, sticky eyes in the morning, and redness of the eyelid margins. Styes and chalazions are also more common in patients with blepharitis, and secondary conjunctivitis may occur.

Management of blepharitis involves softening the lid margin with hot compresses twice a day and practicing lid hygiene to remove debris from the lid margins. This can be done using cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo or sodium bicarbonate in cooled boiled water. Artificial tears may also be given for symptom relief in people with dry eyes or an abnormal tear film.

The most probable diagnosis for this gentleman’s condition is infrapatellar bursitis, which is often associated with kneeling, particularly in clergymen. Although prepatellar bursitis may also be a possible cause, it is more commonly observed in housemaids who kneel in a more upright position. Osteoarthritis, which is characterized by knee pain and a feeling of instability, is more prevalent in individuals over the age of forty-five, making it less likely for this patient. Cruciate ligament damage, meniscal tear, and ruptured bursa are also potential causes, but they are typically associated with a history of trauma.

Knee problems are common among older adults, and it is important to be aware of the key features of each condition. Osteoarthritis of the knee is often seen in patients over 50 years of age who are overweight. This condition can cause severe pain, intermittent swelling, crepitus, and limited movement. Infrapatellar bursitis, also known as Clergyman’s knee, is associated with kneeling, while prepatellar bursitis, or Housemaid’s knee, is associated with more upright kneeling. Anterior cruciate ligament injuries may be caused by twisting of the knee, and patients may have heard a popping noise. Rapid onset of knee effusion and a positive draw test are also common features. Posterior cruciate ligament injuries may be caused by anterior force applied to the proximal tibia, such as during a car accident. Collateral ligament injuries can cause tenderness over the affected ligament and knee effusion. Meniscal lesions may be caused by twisting of the knee and can cause locking and giving-way, as well as tenderness along the joint line.

It is probable that the patient experienced cataplexy, as indicated by their laughter and history of excessive sleepiness during classes, which suggests a potential diagnosis of narcolepsy. While cardiac syncope is a possibility, further investigations such as an ECG and transthoracic echocardiogram would be necessary to rule it out. Absence seizures are unlikely due to the absence of blank staring, and generalized epilepsy is also improbable as it typically involves longer-lasting tonic-clonic seizures with a slower recovery time.

Understanding Cataplexy

Cataplexy is a condition characterized by a sudden and temporary loss of muscle control triggered by intense emotions such as laughter or fear. It is commonly associated with narcolepsy, with around two-thirds of patients experiencing cataplexy. The symptoms of cataplexy can vary from mild buckling of the knees to complete collapse.

This condition can be debilitating and can significantly impact a person’s quality of life. It can also be challenging to diagnose, as the symptoms can be mistaken for other conditions such as seizures or fainting spells. Treatment options for cataplexy include medication and lifestyle changes, such as avoiding triggers that can cause emotional responses.

Strategies for Preventing Alcohol Relapse

For individuals with alcohol-use disorders, preventing relapse is crucial for maintaining sobriety. Here are some strategies that can help:

1. Join a local Alcoholics Anonymous group or other self-help groups that require total abstinence. Active participation in these groups can offer the best chance of preventing relapses.

2. Limit consumption to socially appropriate amounts. Even small amounts of alcohol can trigger a relapse, so individuals who have completed a detoxification program are encouraged not to drink at all.

3. Take disulfiram as prescribed. This medication can cause unpleasant symptoms when alcohol is consumed, making it a deterrent for those who struggle with alcohol use. However, it should only be taken in the context of an appropriate alcohol detoxification program.

4. Take naltrexone as prescribed. This medication can help reduce cravings for alcohol, but it should not be taken as a deterrent before attending a party.

5. Plan a definite number of drinks before attending a party. However, individuals who have completed a detoxification program are still encouraged not to drink at all to prevent relapse.

By implementing these strategies, individuals with alcohol-use disorders can increase their chances of maintaining sobriety and preventing relapse.

The situation is complex as the patient requires bone protection due to her low T score and previous hip fracture. However, bisphosphonates are not suitable for her as they are contraindicated in patients with an eGFR below 35 mL/minute/1.73m(2), which she has due to her stage IV chronic kidney disease. Therefore, reintroducing alendronate or using IV zoledronate infusion is not an option. Repeating her DEXA scan at this point would not provide any additional information. While calcium and vitamin D supplementation should continue, they are not sufficient for her bone protection needs. The best option is denosumab, which would require administration in a secondary care setting and close monitoring of her calcium levels due to her renal disease.

The NICE guidelines for managing osteoporosis in postmenopausal women include offering vitamin D and calcium supplementation, with alendronate being the first-line treatment. If a patient cannot tolerate alendronate, risedronate or etidronate may be given as second-line drugs, with strontium ranelate or raloxifene as options if those cannot be taken. Treatment criteria for patients not taking alendronate are based on age, T-score, and risk factors. Bisphosphonates have been shown to reduce the risk of fractures, with alendronate and risedronate being superior to etidronate in preventing hip fractures. Other treatments include selective estrogen receptor modulators, strontium ranelate, denosumab, teriparatide, and hormone replacement therapy. Hip protectors and falls risk assessment may also be considered in management.

BRCA-1 and BRCA-2 Mutations and Their Association with Cancer

BRCA-1 and BRCA-2 are tumour suppressor genes that play a crucial role in repairing damaged DNA and preventing uncontrolled cell division. Mutations in these genes have been linked to an increased risk of developing various types of cancer, including breast, ovarian, prostate, pancreatic, and colorectal cancers. Ashkenazi Jews have a higher incidence of BRCA mutations, and women with a family history of breast cancer can be tested for these mutations. The risk of developing breast cancer is high for women with abnormal BRCA-1 or -2, but the risk for ovarian cancer is lower. There is currently no association between BRCA-1 mutations and cervical, endometrial, gastric, or lung cancer.

Esophageal cancer is unlikely due to the individual’s good health and two-year history.

Understanding Pharyngeal Pouch or Zenker’s Diverticulum

A pharyngeal pouch, also known as Zenker’s diverticulum, is a condition where there is a posteromedial diverticulum through Killian’s dehiscence. This triangular area is found in the wall of the pharynx between the thyropharyngeus and cricopharyngeus muscles. It is more common in older patients and is five times more common in men.

The symptoms of pharyngeal pouch include dysphagia, regurgitation, aspiration, neck swelling that gurgles on palpation, and halitosis. To diagnose this condition, a barium swallow combined with dynamic video fluoroscopy is usually done.

Surgery is the most common management for pharyngeal pouch. It is important to address this condition promptly to prevent complications such as aspiration pneumonia. Understanding the symptoms and seeking medical attention early can help in the proper management of pharyngeal pouch.

Pseudopolyps observed during endoscopy are indicative of ulcerative colitis.

Crohn’s disease and ulcerative colitis are the two main types of inflammatory bowel disease with many similarities in symptoms and management options. However, there are key differences such as non-bloody diarrhea and upper gastrointestinal symptoms being more common in Crohn’s disease, while bloody diarrhea and abdominal pain in the left lower quadrant are more common in ulcerative colitis. Complications and pathology also differ between the two diseases.

Understanding Complications of ERCP: Pancreatitis, Cholangitis, and More

ERCP (endoscopic retrograde cholangiopancreatography) is a common procedure used to diagnose and treat conditions of the bile ducts and pancreas. However, like any medical procedure, it carries risks and potential complications. One such complication is pancreatitis, which can present with non-specific symptoms but may be accompanied by hypocalcaemia. Immediate management includes confirming the diagnosis and severity of pancreatitis, intravenous fluid resuscitation, oxygen, and adequate analgesia. Another potential complication is ascending cholangitis, which can present with fever, jaundice, and abdominal pain. Biliary perforation is a serious but infrequent complication that is usually recognized during the procedure, while intestinal perforation is not an expected complication. A reaction to contrast would have occurred during the procedure. It is important to understand these potential complications and their symptoms in order to provide prompt and appropriate management.

Diagnostic Tests for Autosomal Dominant Polycystic Kidney Disease (ADPKD)

Autosomal Dominant Polycystic Kidney Disease (ADPKD) is a genetic disorder that affects the kidneys. There are several diagnostic tests available to detect ADPKD, including ultrasonography, full blood count (FBC) and urea and electrolytes (U&Es), PKD1 and 2 gene test, and urinalysis.

Ultrasonography is the preferred test for ADPKD as it can detect cysts from 1 to 1.5 cm without the use of radiation or contrast material. The sensitivity of ultrasonography for ADPKD1 is 99% for at-risk patients older than 20 years. The diagnostic criteria for ADPKD1 were established by Ravine et al. in 1994 and depend on the number of cysts present in each kidney and the age of the patient.

FBC and U&Es are performed to check for any abnormalities in blood count and electrolyte levels. An increased haematocrit in the FBC may result from increased erythropoietin secretion from cysts.

PKD1 and 2 gene test is recommended for young adults with negative ultrasonographic findings who are being considered as potential kidney donors. Genetic testing by means of DNA linkage analysis has an accuracy of >95% for ADPKD1 and ADPKD2.

Urinalysis and urine culture are also performed to check for any abnormalities in the urine. Microalbuminuria occurs in 35% of patients with ADPKD, but nephrotic-range proteinuria is uncommon.

Referral to a geneticist is not necessary at this stage, as initial tests such as ultrasonography can be requested by the general practitioner (GP) in the community. However, patients with ADPKD may benefit from genetic counselling to provide them with more information about their genetic condition and assistance in understanding any options that may be available. This may be with a genetic counsellor, a clinical geneticist or a specialist genetic nurse.

In conclusion, a combination of these diagnostic tests can help in the early detection and management of ADPKD.

Primary biliary cholangitis is a chronic liver disease that primarily affects middle-aged women. It is characterized by the destruction of small bile ducts in the liver, leading to cholestasis and liver damage. The disease is diagnosed through blood tests that measure levels of specific antibodies and liver enzymes, which are highly specific to the condition. Ursodeoxycholic acid is the preferred treatment for slowing disease progression and improving symptoms, while cholestyramine can be used to alleviate itching but does not affect disease progression. In cases of decompensated liver disease, such as when bilirubin levels exceed 100, liver transplantation may be an option. Although recurrence in the graft can occur, it is typically not a significant issue. While fat-soluble vitamins can be supplemented, they are not a primary treatment option.

Primary Biliary Cholangitis: A Chronic Liver Disorder

Primary biliary cholangitis, previously known as primary biliary cirrhosis, is a chronic liver disorder that is commonly observed in middle-aged women. The exact cause of this condition is not yet fully understood, but it is believed to be an autoimmune disease. The disease is characterized by the progressive damage of interlobular bile ducts due to chronic inflammation, leading to cholestasis and eventually cirrhosis. The most common symptom of primary biliary cholangitis is itching in middle-aged women.

This condition is often associated with other autoimmune diseases such as Sjogren’s syndrome, rheumatoid arthritis, systemic sclerosis, and thyroid disease. Early symptoms of primary biliary cholangitis may be asymptomatic or may include fatigue, pruritus, and cholestatic jaundice. Late symptoms may progress to liver failure. Diagnosis of primary biliary cholangitis involves immunology tests such as anti-mitochondrial antibodies (AMA) M2 subtype and smooth muscle antibodies, as well as imaging tests to exclude an extrahepatic biliary obstruction.

The first-line treatment for primary biliary cholangitis is ursodeoxycholic acid, which slows down the progression of the disease and improves symptoms. Cholestyramine is used to alleviate pruritus, and fat-soluble vitamin supplementation is recommended. In severe cases, liver transplantation may be necessary, especially if bilirubin levels exceed 100. However, recurrence in the graft can occur, but it is not usually a problem. Complications of primary biliary cholangitis include cirrhosis, portal hypertension, ascites, variceal hemorrhage, osteomalacia, osteoporosis, and an increased risk of hepatocellular carcinoma.

The chest compressions to ventilations ratio should be 15:2 when two trained staff members are present.

Paediatric Basic Life Support Guidelines

Paediatric basic life support guidelines were updated in 2015 by the Resuscitation Council. Lay rescuers should use a compression:ventilation ratio of 30:2 for children under 1 year and between 1 year and puberty, a child is defined. If there are two or more rescuers, a ratio of 15:2 should be used.

The algorithm for paediatric basic life support starts with checking if the child is unresponsive and shouting for help. The airway should be opened, and breathing should be checked by looking, listening, and feeling for breaths. If the child is not breathing, five rescue breaths should be given, and signs of circulation should be checked.

For infants, the brachial or femoral pulse should be used, while children should use the femoral pulse. Chest compressions should be performed at a ratio of 15:2, with a rate of 100-120 compressions per minute for both infants and children. The depth of compressions should be at least one-third of the anterior-posterior dimension of the chest, which is approximately 4 cm for an infant and 5 cm for a child.

In children, the lower half of the sternum should be compressed, while in infants, a two-thumb encircling technique should be used for chest compressions. These guidelines are crucial for anyone who may need to perform basic life support on a child, and it is essential to follow them carefully to ensure the best possible outcome.