To calculate the relative risk (RR), we need to determine the event rates in both the experiment group (EER) and the control group (CER). The EER is the number of patients who experience a specific event in the experiment group divided by the total number of patients in that group. Similarly, the CER is the number of patients who experience the same event in the control group divided by the total number of patients in that group. The RR is then calculated by dividing the EER by the CER. For example, in this study, the EER is the number of patients who achieve significant symptom relief after taking ibuprofen, while the CER is the number of patients who achieve the same relief after taking a placebo.

Understanding Relative Risk in Clinical Trials

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

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

The most likely diagnosis for this man with biochemical evidence of hypothyroidism and raised anti-TPO antibodies is Hashimoto’s thyroiditis, which is characterized by hypothyroidism, goitre, and anti-TPO antibodies. Exophthalmos, hypercalcaemia, and onycholysis are not typically associated with Hashimoto’s thyroiditis, but rather with other thyroid disorders such as Graves’ disease.

Understanding Hashimoto’s Thyroiditis

Hashimoto’s thyroiditis is a chronic autoimmune disorder that affects the thyroid gland. It is more common in women and is typically associated with hypothyroidism, although there may be a temporary period of thyrotoxicosis during the acute phase. The condition is characterized by a firm, non-tender goitre and the presence of anti-thyroid peroxidase (TPO) and anti-thyroglobulin (Tg) antibodies.

Hashimoto’s thyroiditis is often associated with other autoimmune conditions such as coeliac disease, type 1 diabetes mellitus, and vitiligo. Additionally, there is an increased risk of developing MALT lymphoma with this condition. It is important to note that many causes of hypothyroidism may have an initial thyrotoxic phase, as shown in the Venn diagram. Understanding the features and associations of Hashimoto’s thyroiditis can aid in its diagnosis and management.

Causes and Characteristics of Unilateral Ptosis and Lid Lag in Thyrotoxicosis

Unilateral ptosis, or drooping of one eyelid, can be caused by disinsertion of the aponeurosis of the levator palpabrae superioris, Horner syndrome, or a third nerve palsy. Local inflammation of the conjunctiva can also lead to ptosis. Myasthenia gravis typically results in bilateral ptosis, but it may be asymmetrical.

Disinsertion of the aponeurosis of the levator palpabrae superioris is characterized by the loss of the crease normally seen on the upper eyelid and is often due to dysfunction of the superior rectus and levator muscles. It may be iatrogenic or degenerative due to senility.

Lid lag, where the upper eyelid lags behind the upper edge of the iris as the eye moves downward, is a common characteristic of thyrotoxicosis. A similar phenomenon can occur with the lower edge when the eye moves upwards.

In cases where weakness of hand muscles is present, a T1 root lesion is likely, indicating Horner syndrome. Miosis, or constriction of the pupil, can be subtle and easily missed. In smokers, a high suspicion of a Pancoast’s tumor (apical pulmonary tumor) should be considered in patients with such a presentation.

NICE suggests including an antibiotic only when the sputum shows signs of being purulent.

The National Institute for Health and Care Excellence (NICE) updated its guidelines on the management of chronic obstructive pulmonary disease (COPD) in 2018. The guidelines recommend general management strategies such as smoking cessation advice, annual influenza vaccination, and one-off pneumococcal vaccination. Pulmonary rehabilitation is also recommended for patients who view themselves as functionally disabled by COPD.

Bronchodilator therapy is the first-line treatment for patients who remain breathless or have exacerbations despite using short-acting bronchodilators. The next step is determined by whether the patient has asthmatic features or features suggesting steroid responsiveness. NICE suggests several criteria to determine this, including a previous diagnosis of asthma or atopy, a higher blood eosinophil count, substantial variation in FEV1 over time, and substantial diurnal variation in peak expiratory flow.

If the patient doesn’t have asthmatic features or features suggesting steroid responsiveness, a long-acting beta2-agonist (LABA) and long-acting muscarinic antagonist (LAMA) should be added. If the patient is already taking a short-acting muscarinic antagonist (SAMA), it should be discontinued and switched to a short-acting beta2-agonist (SABA). If the patient has asthmatic features or features suggesting steroid responsiveness, a LABA and inhaled corticosteroid (ICS) should be added. If the patient remains breathless or has exacerbations, triple therapy (LAMA + LABA + ICS) should be offered.

NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot use inhaled therapy. Azithromycin prophylaxis is recommended in select patients who have optimised standard treatments and continue to have exacerbations. Mucolytics should be considered in patients with a chronic productive cough and continued if symptoms improve.

Cor pulmonale features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, and loud P2. Loop diuretics should be used for oedema, and long-term oxygen therapy should be considered. Smoking cessation, long-term oxygen therapy in eligible patients, and lung volume reduction surgery in selected patients may improve survival in patients with stable COPD. NICE doesn’t recommend the use of ACE-inhibitors, calcium channel blockers, or alpha blockers

Lithium levels should be monitored weekly after a change in dose until they become stable. This means that after an increase in lithium dose, the levels should be checked again after one week, and then weekly until they stabilize. The ideal time to check lithium levels is 12 hours after the dose is taken. Waiting for a month after a dose adjustment is too long, while checking after three days is too soon. Once the levels become stable, they can be checked every three months for the first year. After a year, low-risk patients can have their lithium testing reduced to every six months, according to the BNF. However, NICE guidance recommends that three-monthly testing should continue indefinitely. Additionally, patients on lithium should have their thyroid function tests monitored every six months.

Lithium is a medication used to stabilize mood in individuals with bipolar disorder and as an adjunct in refractory depression. It has a narrow therapeutic range of 0.4-1.0 mmol/L and is primarily excreted by the kidneys. The mechanism of action is not fully understood, but it is believed to interfere with inositol triphosphate or cAMP formation.

Common adverse effects of lithium include nausea, vomiting, diarrhea, fine tremors, and nephrotoxicity. It may also cause thyroid enlargement, ECG changes, weight gain, idiopathic intracranial hypertension, leucocytosis, and hyperparathyroidism.

Monitoring of patients on lithium therapy is crucial to prevent toxicity. It is recommended to check lithium levels 12 hours after the last dose and weekly after starting or changing the dose until concentrations are stable. Once established, lithium levels should be checked every 3 months. Thyroid and renal function should be checked every 6 months. Patients should be provided with an information booklet, alert card, and record book. Inadequate monitoring of patients taking lithium is common, and guidelines have been issued to address this issue.

Ethical Considerations in Cancer Treatment

There are several ethical considerations to be taken into account when treating a patient with cancer. Firstly, the doctor must use their specialist knowledge, experience, clinical judgement, and the patient’s views and understanding of their condition to identify which investigations or treatments are clinically appropriate and likely to result in overall benefit for the patient. It is also important to note that a patient should not be pressured into accepting investigation or treatment against their will.

In the case of a patient with capacity, they are entitled to a confidential consultation. While it is acceptable to ask if they would like their family members present, it is ultimately up to the patient to decide. As a GP, it is important to provide expert advice to the patient, even if you are not an oncologist. However, if you disagree with a prescribed treatment and have no evidence that it would benefit the patient, you do not have to agree to it.

If the patient has not requested a referral to another consultant, it is still appropriate to offer a second opinion should they disagree with their oncologist’s views. The focus of the consultation should be on discussing the pros and cons of treatment options, with the ultimate goal of providing the patient with the best possible care.

If there is suspicion of a DVT and it is not possible to obtain a D-dimer or scan result within four hours, NICE recommends initiating anticoagulation treatment with a DOAC such as apixaban. Low molecular weight heparin is no longer the preferred option. Clopidogrel is not effective in treating DVT. Warfarin, which was previously used, has been largely replaced by DOACs, but may still be used in some cases with low molecular weight heparin until the INR is within target range.

Deep vein thrombosis (DVT) is a serious condition that requires prompt diagnosis and management. The National Institute for Health and Care Excellence (NICE) updated their guidelines in 2020, recommending the use of direct oral anticoagulants (DOACs) as first-line treatment for most people with VTE, including as interim anticoagulants before a definite diagnosis is made. They also recommend the use of DOACs in patients with active cancer, as opposed to low-molecular weight heparin as was previously recommended. Routine cancer screening is no longer recommended following a VTE diagnosis.

If a patient is suspected of having a DVT, a two-level DVT Wells score should be performed to assess the likelihood of the condition. If a DVT is ‘likely’ (2 points or more), a proximal leg vein ultrasound scan should be carried out within 4 hours. If the result is positive, then a diagnosis of DVT is made and anticoagulant treatment should start. If the result is negative, a D-dimer test should be arranged. If a proximal leg vein ultrasound scan cannot be carried out within 4 hours, a D-dimer test should be performed and interim therapeutic anticoagulation administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours).

The cornerstone of VTE management is anticoagulant therapy. The big change in the 2020 guidelines was the increased use of DOACs. Apixaban or rivaroxaban (both DOACs) should be offered first-line following the diagnosis of a DVT. Instead of using low-molecular weight heparin (LMWH) until the diagnosis is confirmed, NICE now advocate using a DOAC once a diagnosis is suspected, with this continued if the diagnosis is confirmed. If neither apixaban or rivaroxaban are suitable, then either LMWH followed by dabigatran or edoxaban OR LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin) can be used.

All patients should have anticoagulation for at least 3 months. Continuing anticoagulation after this period is partly determined by whether the VTE was provoked or unprovoked. If the VTE was provoked, the treatment is typically stopped after the initial 3 months (3 to 6 months for people with active cancer). If the VTE was

The recommended first-line treatment for hypoglycaemia in a conscious patient who is able to swallow is a fast-acting carbohydrate in the form of glucose liquids, tablets, or gels. In this case, the patient is conscious and able to swallow, so an oral glucose gel is the best option to quickly increase their blood glucose level.

Administering intramuscular glucagon is not necessary in this situation as the patient is conscious and able to take oral glucose. However, if the patient becomes combative and unable to take any oral glucose, intramuscular glucagon may be considered.

Intravenous administration is not a recommended route for glucagon and is therefore not a suitable option.

Intravenous glucose is not necessary for this patient as they are conscious and able to take glucose orally. It may be considered in a hospital setting for patients who are unable to take glucose orally.

Understanding Hypoglycaemia: Causes, Features, and Management

Hypoglycaemia is a condition characterized by low blood sugar levels, which can lead to a range of symptoms and complications. There are several possible causes of hypoglycaemia, including insulinoma, liver failure, Addison’s disease, and alcohol consumption. The physiological response to hypoglycaemia involves hormonal and sympathoadrenal responses, which can result in autonomic and neuroglycopenic symptoms. While blood glucose levels and symptom severity are not always correlated, common symptoms of hypoglycaemia include sweating, shaking, hunger, anxiety, nausea, weakness, vision changes, confusion, and dizziness. In severe cases, hypoglycaemia can lead to convulsions or coma.

Managing hypoglycaemia depends on the severity of the symptoms and the setting in which it occurs. In the community, individuals with diabetes who inject insulin may be advised to consume oral glucose or a quick-acting carbohydrate such as GlucoGel or Dextrogel. A ‘HypoKit’ containing glucagon may also be prescribed for home use. In a hospital setting, treatment may involve administering a quick-acting carbohydrate or subcutaneous/intramuscular injection of glucagon for unconscious or unable to swallow patients. Alternatively, intravenous glucose solution may be given through a large vein.

Overall, understanding the causes, features, and management of hypoglycaemia is crucial for individuals with diabetes or other conditions that increase the risk of low blood sugar levels. Prompt and appropriate treatment can help prevent complications and improve outcomes.

Common Personality and Mental Health Disorders

Dependent Personality Disorder: This disorder is characterized by a person’s inability to make decisions on their own and a constant need for reassurance and support from others.

Borderline Personality Disorder: Individuals with this disorder experience intense mood swings, unstable relationships, and may engage in self-harm or have suicidal tendencies.

Conversion Disorder: This disorder involves physical symptoms that mimic a medical condition, but have no underlying medical cause.

Depression: A mental health disorder characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities.

Histrionic Personality Disorder: People with this disorder have a strong desire for attention and may engage in dramatic or seductive behavior to gain approval from others.

The use of gel can provide relief from symptoms. However, the main goal of treatment is to minimize the risk of transmission to the newborn during delivery. This risk is particularly high if the woman experiences primary genital herpes simplex during the last six weeks of pregnancy. In such cases, a caesarean section is the recommended method of delivery.

The herpes simplex virus (HSV) comes in two strains: HSV-1 and HSV-2. It was once believed that HSV-1 caused cold sores and HSV-2 caused genital herpes, but there is now significant overlap between the two. Symptoms of a primary infection may include severe gingivostomatitis, while cold sores and painful genital ulceration are also common. Treatment options include oral aciclovir and chlorhexidine mouthwash for gingivostomatitis, topical aciclovir for cold sores (although the evidence for its effectiveness is limited), and oral aciclovir for genital herpes. Pregnant women with herpes should be treated with suppressive therapy, and those who experience a primary attack during pregnancy after 28 weeks gestation should have an elective caesarean section. The risk of transmission to the baby is low for women with recurrent herpes. Pap smear images can show the cytopathic effect of HSV, including multinucleation, marginated chromatin, and molding of the nuclei.

Topical Oestrogens for Genitourinary Symptoms of Menopause

Topical oestrogens can be used alongside transdermal/oral HRT to treat genitourinary symptoms of menopause. In fact, systemic HRT doesn’t improve these symptoms in 10-15% of women. Topical oestrogens are effective in these cases and can be combined with systemic HRT.

Combined HRT is not better than oestrogen-only therapy for treating genitourinary symptoms, and progestogens are only used for endometrial protection. If a patient already has protection via an IUS, combination therapy would not be beneficial. Topical oestrogen preparations have been shown to improve vaginal symptoms, including vaginal atrophy and pH decrease, and to increase epithelial maturation compared to placebo or non-hormonal gels.

It is important to note that systemic absorption of vaginal oestrogen is very low. Therefore, topical oestrogens work better for genitourinary symptoms of menopause compared to oral HRT and can be used in combination. According to NICE NG23, vaginal oestrogen should be offered to women with urogenital atrophy, including those on systemic HRT, and treatment should continue for as long as needed to relieve symptoms.

If vaginal oestrogen doesn’t relieve symptoms, the dose can be increased after seeking advice from a healthcare professional with expertise in menopause. Women should be informed that symptoms often return when treatment is stopped, but adverse effects from vaginal oestrogen are very rare. They should report any unscheduled vaginal bleeding to their GP. Additionally, moisturisers and lubricants can be used alone or in addition to vaginal oestrogen for vaginal dryness. Routine monitoring of endometrial thickness during treatment for urogenital atrophy is not necessary.

Medication Management in Renal Impairment: A Case Study

In managing patients with renal impairment, it is important to consider the potential risks and benefits of medication use. In this case study, we will review the medication regimen of a patient with an eGFR level of 36 ml/min per 1.73 m2 and discuss any necessary adjustments.

Metformin carries a risk of lactic acidosis and should be avoided if the patient’s eGFR is ≤ 30 ml/min per 1.73 m2. The dose should be reviewed if the eGFR is ≤ 45 ml/min per 1.73 m2. Treatment should also be withdrawn in patients at risk of tissue hypoxia or sudden deterioration in renal function.

Sertraline, a selective serotonin reuptake inhibitor used in the treatment of depression, can be used with caution in renal failure and doesn’t require dose reduction.

Finasteride, used to treat BPH, doesn’t require dose adjustment in those with renal failure.

Tamsulosin, also used to treat BPH, should be used with caution in patients with an eGFR level < 10 ml/min per 1.73 m2. However, this patient's eGFR level of 36 ml/min per 1.73 m2 doesn't meet this threshold, so no adjustment is necessary at this time. Nifedipine, used to treat hypertension and angina, doesn’t require dose modification in those with renal impairment. In conclusion, medication management in renal impairment requires careful consideration of each patient’s individual case and potential risks and benefits of medication use. Close monitoring and regular review of medication regimens are essential to ensure optimal patient outcomes.

Hypercalcaemia and hypocalciuria may be caused by thiazide diuretics.

The onset of action of bendroflumethiazide is 1 to 2 hours, and its effect lasts for 12 to 24 hours. According to the BNF, the quantity of bendroflumethiazide present in breast milk is insignificant and poses no harm.

Thiazide diuretics are medications that work by blocking the thiazide-sensitive Na+-Cl− symporter, which inhibits sodium reabsorption at the beginning of the distal convoluted tubule (DCT). This results in the loss of potassium as more sodium reaches the collecting ducts. While thiazide diuretics are useful in treating mild heart failure, loop diuretics are more effective in reducing overload. Bendroflumethiazide was previously used to manage hypertension, but recent NICE guidelines recommend other thiazide-like diuretics such as indapamide and chlortalidone.

Common side effects of thiazide diuretics include dehydration, postural hypotension, and electrolyte imbalances such as hyponatremia, hypokalemia, and hypercalcemia. Other potential adverse effects include gout, impaired glucose tolerance, and impotence. Rare side effects may include thrombocytopenia, agranulocytosis, photosensitivity rash, and pancreatitis.

It is worth noting that while thiazide diuretics may cause hypercalcemia, they can also reduce the incidence of renal stones by decreasing urinary calcium excretion. According to current NICE guidelines, the management of hypertension involves the use of thiazide-like diuretics, along with other medications and lifestyle changes, to achieve optimal blood pressure control and reduce the risk of cardiovascular disease.

Giant Cell Temporal Arteritis: Urgent Management Required

This patient’s history strongly suggests giant cell temporal arteritis (GCA), a medical emergency that requires urgent management. While ophthalmologists may be involved in the management of GCA, their involvement is only necessary if the condition is affecting the patient’s vision. In this scenario, the patient’s vision is not affected.

The recommended course of action is to start the patient on 40-60mg of prednisolone per day (for patients without visual symptoms) and refer them urgently to a physician, typically a Rheumatologist. It is important to note that national guidance should be followed, rather than local variations, when assessing patients in an exam setting. Shared care is recommended, and patients may require treatment for several years.

In addition to steroids, aspirin and PPIs are recommended. However, long-term treatment with oral steroids can increase the risk of osteoporosis, which should be assessed. For more information on national guidance and associated information, CKS provides a comprehensive summary of GCA management.

Febrile Seizures: Risk Factors, Recurrence, Immunizations, and Management

Febrile seizures are common in young children and can be a cause of concern for parents. Here are some important points to keep in mind:

Risk Factors: The likelihood of epilepsy increases if the child has a complex febrile seizure (prolonged seizure, multiple seizures or seizure with focal features), if there is a neurological abnormality, if there is a family history of epilepsy and if the duration of fever was less than one hour before the seizure. Without these features, there is only a small increase in risk compared with the general population.

Recurrence: Recurrent febrile seizures occur in about 30% of cases. Risk factors for later recurrences of febrile seizures include onset before 18 months, a seizure with a lower temperature close to 38°C, a shorter duration of fever (less than one hour) before the seizure and a family history of febrile seizures.

Immunizations: Childhood immunizations should continue even if the febrile seizure followed an immunization. Immunization doesn’t increase the risk of further seizures.

Management: Antipyretic drugs may be given to reduce fever but there is no evidence they reduce the number of febrile seizures. Anticonvulsant drugs should not be routinely prescribed. There is no evidence that intellect is affected, even for children with complex febrile seizures.

Insulin therapy can have side-effects that patients should be aware of. One of the most common side-effects is hypoglycaemia, which can cause sweating, anxiety, blurred vision, confusion, and aggression. Patients should be taught to recognize these symptoms and take 10-20g of a short-acting carbohydrate, such as a glass of Lucozade or non-diet drink, three or more glucose tablets, or glucose gel. It is also important for every person treated with insulin to have a glucagon kit for emergencies where the patient is not able to orally ingest a short-acting carbohydrate. Patients who have frequent hypoglycaemic episodes may develop reduced awareness, and beta-blockers can further reduce hypoglycaemic awareness.

Another potential side-effect of insulin therapy is lipodystrophy, which typically presents as atrophy or lumps of subcutaneous fat. This can be prevented by rotating the injection site, as using the same site repeatedly can cause erratic insulin absorption. It is important for patients to be aware of these potential side-effects and to discuss any concerns with their healthcare provider. By monitoring their blood sugar levels and following their treatment plan, patients can manage the risks associated with insulin therapy and maintain good health.

Severity of Ulcerative Colitis and the Truelove-Witts Criteria

Severe flare-ups of inflammatory bowel disease can lead to serious complications such as toxic megacolon, perforation, sepsis, and severe bleeding. Hospital admission and inpatient treatment are necessary in such cases. Severe ulcerative colitis is characterized by significant systemic upset and severe lower gastrointestinal symptoms. Blood investigations can provide further information on disease severity.

The Truelove-Witts criteria are a validated way of stratifying disease severity. According to these criteria, acute severe ulcerative colitis is defined as bowels open more than six times daily plus one or more of the following: haemoglobin less than 105 g/L, ESR greater than 30 mm/hr, pulse rate greater than 90 bpm, and temperature greater than 37.8°C.

If a patient presents with bloody diarrhea and systemic unwellness (fever and/or tachycardia), immediate hospital admission for in-patient assessment is necessary. Approximately half of severe ulcerative colitis attacks occur as a first attack in a patient without a previous diagnosis.

Moderate disease is classified as four to six stools a day (with or without blood) with minimal systemic disturbance. Mild disease is classified as less than four stools a day (with or without blood) with no systemic unwellness (no fever or tachycardia) and a normal ESR.

It is important to note that anti-diarrheal agents such as loperamide should be avoided as they have not been shown to reduce stool frequency in ulcerative colitis and have been associated with an increased risk of toxic megacolon. Studies from the 1950s show that untreated severe ulcerative colitis had a mortality rate of almost 25%, but with the use of corticosteroids and expert surgical input, this figure has been reduced to less than 1%.

• Sensitivity (Sens): The probability that the test is positive given that the disease is present. In this case, it is 80% or 0.80.
• Specificity (Spec): The probability that the test is negative given that the disease is not present. In this case, it is 85% or 0.85.
• Likelihood Ratio for a Negative Test Result (LR): The ratio of the probability of a negative test result in patients with the disease to the probability of a negative test result in patients without the disease. It is calculated as:

  LR−=(1−Sensitivity)/Specificity​

Calculation

Using the provided sensitivity and specificity:

• Sensitivity = 0.80
• Specificity = 0.85

Substitute these values into the formula for the negative likelihood ratio:

LR=(1−Sensitivity)/Specificity

LR=(1−0.80)/0.85​

LR=0.20/0.85

$$\text{LR}\approx 0.235$$

Peritonsillar Abscess: A Serious Complication of Sore Throat

When evaluating a patient with a sore throat, it is crucial for clinicians to be aware of any potential serious causes or complications. One such condition is a peritonsillar abscess, which requires hospital admission and immediate treatment.

A peritonsillar abscess can lead to airway obstruction, deeper spread of infection, and abscess rupture. Therefore, it is important to check for clinical features such as difficulty swallowing, fever, and severe throat pain.

The initial management for a peritonsillar abscess is to arrange hospital admission. Once admitted, the patient can receive inpatient treatment in a safe environment with immediate care and monitoring. Treatment typically involves aspiration or drainage of the abscess, along with antibiotic use and pain relief.

In summary, a peritonsillar abscess is a serious complication of sore throat that requires prompt recognition and management. Hospital admission is necessary to ensure the patient’s safety and prevent further complications.

Understanding Migraine: Symptoms, Triggers, and Risks

Migraine is a neurological condition that is often characterized by a prodromal aura preceding a severe headache that can last for several hours or even days. While the first attack usually occurs in childhood, over 80% of individuals experience their first migraine by the age of 30. However, if the onset of migraine occurs after the age of 50, other underlying conditions should be investigated.

While certain foods and additives such as caffeine, chocolate, and aged cheese have been suggested as potential triggers for migraine, large epidemiological studies have failed to confirm these claims. As such, no specific diets have been shown to alleviate migraine symptoms.

It is important to note that both migraine and the use of combined oral contraceptives are independent risk factors for ischemic stroke. However, the risk is low in the absence of other risk factors, and migraine without aura is not a contraindication for the use of combined oral contraceptives. Women with other risk factors for arterial disease should use caution when taking the pill, and those with prothrombotic coagulation disorders should avoid it altogether.

Hemiplegic migraine is a rare form of migraine that is characterized by unilateral weakness that accompanies a migraine headache attack. This form of migraine with aura may occur either in families or only in one individual. It is important to distinguish between migraine aura and other conditions such as epileptic aura or transient ischemic attack, which have different characteristics.

In summary, understanding the symptoms, triggers, and risks associated with migraine is crucial for effective management and treatment of this debilitating condition.

According to the GMC, doctors should refrain from treating themselves or individuals with whom they have a close personal relationship. It is recommended that doctors register with a GP outside of their family. Therefore, the most appropriate course of action would be to suggest that the colleague consults with their own GP. Discussing their medical history could create confusion regarding the doctor-patient relationship. Urging them to visit A&E is not advisable as it is not an emergency or an accident. It is worth noting that this type of request is not uncommon among colleagues, and reporting it to the GMC may be considered excessive.

Injectable progesterone contraceptives are not recommended for individuals with current breast cancer due to contraindications. This applies to all hormonal contraceptive options, including Depo-Provera, which are classified as UKMEC 4. As a result, the copper intrauterine device is the only suitable contraception option available.

Injectable Contraceptives: Depo Provera

Injectable contraceptives are a popular form of birth control in the UK, with Depo Provera being the main option available. This contraceptive contains 150 mg of medroxyprogesterone acetate and is administered via intramuscular injection every 12 weeks. It can be given up to 14 weeks after the last dose without the need for extra precautions. The primary method of action is by inhibiting ovulation, while secondary effects include cervical mucous thickening and endometrial thinning.

However, there are some disadvantages to using Depo Provera. Once the injection is given, it cannot be reversed, and there may be a delayed return to fertility of up to 12 months. Adverse effects may include irregular bleeding and weight gain, and there is a potential increased risk of osteoporosis. It should only be used in adolescents if no other method of contraception is suitable.

It is important to note that Noristerat, another injectable contraceptive licensed in the UK, is rarely used in clinical practice. It is given every 8 weeks. The BNF gives different advice regarding the interval between injections, stating that a pregnancy test should be done if the interval is greater than 12 weeks and 5 days. However, this is not commonly adhered to in the family planning community.

The combination of methotrexate and antibiotics containing trimethoprim can lead to bone marrow suppression and potentially fatal pancytopenia. Therefore, it is important to avoid using trimethoprim and co-trimoxazole with methotrexate due to their anti-folate properties, which can cause folate depletion. Fatal cases of megaloblastic anemia and pancytopenia have been reported. Nitrofurantoin and cefalexin do not have any known interactions with methotrexate, and penicillins may reduce its excretion.

Methotrexate is an antimetabolite that hinders the activity of dihydrofolate reductase, an enzyme that is crucial for the synthesis of purines and pyrimidines. It is a significant drug that can effectively control diseases, but its side-effects can be life-threatening. Therefore, careful prescribing and close monitoring are essential. Methotrexate is commonly used to treat inflammatory arthritis, especially rheumatoid arthritis, psoriasis, and acute lymphoblastic leukaemia. However, it can cause adverse effects such as mucositis, myelosuppression, pneumonitis, pulmonary fibrosis, and liver fibrosis.

Women should avoid pregnancy for at least six months after stopping methotrexate treatment, and men using methotrexate should use effective contraception for at least six months after treatment. Prescribing methotrexate requires familiarity with guidelines relating to its use. It is taken weekly, and FBC, U&E, and LFTs need to be regularly monitored. Folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after methotrexate dose. The starting dose of methotrexate is 7.5 mg weekly, and only one strength of methotrexate tablet should be prescribed.

It is important to avoid prescribing trimethoprim or co-trimoxazole concurrently as it increases the risk of marrow aplasia. High-dose aspirin also increases the risk of methotrexate toxicity due to reduced excretion. In case of methotrexate toxicity, the treatment of choice is folinic acid. Overall, methotrexate is a potent drug that requires careful prescribing and monitoring to ensure its effectiveness and safety.

Individuals who exhibit obsessive-compulsive personality traits tend to be inflexible when it comes to their principles, beliefs, and standards, and frequently exhibit hesitancy in delegating tasks to others.

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

The choice of contraceptive for women may be affected by comorbidities. The FSRH provides UKMEC recommendations for different conditions. Smoking increases the risk of cardiovascular disease, and the COCP is recommended as UKMEC 2 for women under 35 and UKMEC 3 for those over 35 who smoke less than 15 cigarettes/day, but is UKMEC 4 for those who smoke more. Obesity increases the risk of venous thromboembolism, and the COCP is recommended as UKMEC 2 for women with a BMI of 30-34 kg/m² and UKMEC 3 for those with a BMI of 35 kg/m² or more. The COCP is contraindicated for women with a history of migraine with aura, but is UKMEC 3 for those with migraines without aura and UKMEC 2 for initiation. For women with epilepsy, consistent use of condoms is recommended in addition to other forms of contraception. The choice of contraceptive for women taking anti-epileptic medication depends on the specific medication, with the COCP and POP being UKMEC 3 for most medications, while the implant is UKMEC 2 and the Depo-Provera, IUD, and IUS are UKMEC 1. Lamotrigine has different recommendations, with the COCP being UKMEC 3 and the POP, implant, Depo-Provera, IUD, and IUS being UKMEC 1.

The Risks of Hypnotic Dependence

Hypnotic dependence remains a significant concern, as benzodiazepines and Z-class drugs have the potential to cause dependence without proven efficacy in treating chronic insomnia. Withdrawal from these drugs can lead to rebound insomnia and even seizures with high doses of benzodiazepines. Additionally, hypnotics have a street value and can be diverted for non-medical use. To mitigate these risks, it is recommended that prescriptions for hypnotics be limited to one week. If a doctor wishes to withdraw a patient from a hypnotic, they should first convert the dosage to an equivalent dose of diazepam, which has a longer half-life, allowing for a slower withdrawal process.

Treatment Ladder for Asthma in a 9-Year-Old Child

Here we have a 9-year-old child with asthma who is currently on a regular inhaled corticosteroid (ICS) + long acting beta2 agonist (LABA) combination inhaler and salbutamol as needed. Despite some improvement with the regular inhaled ICS+LABA, the child is still requiring salbutamol quite frequently.

To guide treatment titration, the British Thoracic Society treatment ladder is the best recognized guideline in the UK. Based on this, the next step would be to trial a leukotriene receptor antagonist. If the addition of the LABA had not yielded any clinical benefit, then it should be stopped. However, since it has proved to be somewhat helpful, it should be continued.

In summary, the treatment ladder for asthma in a 9-year-old child involves gradually increasing the level of medication until symptoms are controlled. The addition of a leukotriene receptor antagonist may be the next step in this process.

Understanding Cataracts and Driving Requirements

It is common for individuals to develop nuclear sclerotic cataracts as they age. However, there is no need for referral unless there is a visual impairment that affects the patient’s lifestyle. If a person has a visual acuity of 6/5, it means they can read at a distance of six meters what a person with normal vision can read at five meters. Therefore, if a patient has excellent vision, they are unlikely to benefit from new glasses.

There is no indication for a person to stop driving if they meet the minimum eyesight standard for driving, which is a visual acuity of at least 6/12 measured on the Snellen scale. To drive legally, a person must also be able to read a car number plate made after 1 September 2001 from a distance of 20 meters, with glasses or contact lenses if necessary.

It is important to note that YAG laser capsulotomy is a procedure carried out for posterior capsular opacification, which can develop after cataract extraction. This procedure is not necessary for a patient with nuclear sclerotic cataracts and would not benefit them.

Distinguishing Skin Conditions: Pityriasis Rosea, Guttate Psoriasis, Drug Eruption, Pityriasis Versicolor, and Viral Exanthema

Pityriasis rosea is characterized by a larger herald patch followed by a rash on the trunk with pink macules and fine scale. The rash will resolve on its own in 6-12 weeks, but emollients or steroid treatments can help relieve itch. Guttate psoriasis typically presents with small lesions preceded by a sore throat, which is not seen in this scenario. Drug eruption causes a maculopapular rash that begins on the trunk and moves to the extremities, but there is no mention of medication in this case. Pityriasis versicolor causes large macules with fine scale on the trunk, which can become confluent, but this is not seen here. A viral exanthem is usually accompanied by systemic symptoms such as fever or malaise, which are absent in this case. Knowing the distinguishing features of these skin conditions can aid in accurate diagnosis and treatment.

Serological Testing for Coeliac Disease

Serological testing for coeliac disease should be considered for individuals presenting with certain symptoms such as chronic diarrhoea, unexplained weight loss, and persistent fatigue. Additionally, those with autoimmune thyroid disease, irritable bowel syndrome, and type 1 diabetes should also be offered testing as they are at increased risk for coeliac disease. NICE guidance recommends testing for individuals with unexplained abdominal symptoms, mouth ulcers, and vitamin deficiencies, as well as first-degree relatives of those with coeliac disease. Coeliac disease is associated with a variety of conditions, including depression, epilepsy, and reduced bone mineral density, among others. In the case of a man with type 1 diabetes and iron deficiency anaemia, serological testing for coeliac disease would be the next appropriate step.