Understanding Polycythemia Rubra Vera: Symptoms, Diagnosis, and Treatment

Polycythemia rubra vera is a rare blood disorder that causes the body to produce too many red blood cells. A person with this condition may experience generalized pruritus, splenomegaly, thrombocytosis, and neutrophil leukocytosis. To confirm the diagnosis, a blood test for a specific mutation (JAK2) present in more than 95% of people with polycythemia vera is necessary.

Without treatment, the life expectancy of a person with polycythemia rubra vera is only 6-18 months. This is due to the high risk of thrombosis, which can lead to ischaemic stroke and myocardial infarction. Venous and arterial thrombosis can also cause other complications such as pulmonary emboli, renal failure, intestinal ischaemia, and peripheral arterial emboli. Bleeding is also a common complication, usually resulting from vascular occlusion due to thrombosis or hyperviscosity. Acute leukaemia, myelofibrosis, and peptic ulcer disease are also possible complications.

However, with treatment to maintain a normal haematocrit, the life expectancy of a person with polycythemia rubra vera can increase to an average of 20 years. While this is still reduced compared to the general population, it is a significant improvement. It is important for individuals with this condition to receive proper medical care and monitoring to manage their symptoms and reduce the risk of complications.

When it comes to the risk of pancreatitis, mesalazine is more likely to cause it than sulfasalazine. Although oral aminosalicylates can cause gastric side-effects such as diarrhoea, nausea, vomiting, and colitis exacerbation, acute pancreatitis is a rare but possible complication.

Aminosalicylate Drugs for Inflammatory Bowel Disease

Aminosalicylate drugs are commonly used to treat inflammatory bowel disease (IBD). These drugs work by releasing 5-aminosalicyclic acid (5-ASA) in the colon, which acts as an anti-inflammatory agent. The exact mechanism of action is not fully understood, but it is believed that 5-ASA may inhibit prostaglandin synthesis.

Sulphasalazine is a combination of sulphapyridine and 5-ASA. However, many of the side effects associated with this drug are due to the sulphapyridine component, such as rashes, oligospermia, headache, Heinz body anaemia, megaloblastic anaemia, and lung fibrosis. Mesalazine is a delayed release form of 5-ASA that avoids the sulphapyridine side effects seen in patients taking sulphasalazine. However, it is still associated with side effects such as gastrointestinal upset, headache, agranulocytosis, pancreatitis, and interstitial nephritis.

Olsalazine is another aminosalicylate drug that consists of two molecules of 5-ASA linked by a diazo bond, which is broken down by colonic bacteria. It is important to note that aminosalicylates are associated with a variety of haematological adverse effects, including agranulocytosis. Therefore, a full blood count is a key investigation in an unwell patient taking these drugs. Pancreatitis is also more common in patients taking mesalazine compared to sulfasalazine.

Investigating Acute Bowel Symptoms in a Patient with Irritable Bowel Syndrome

When a patient with a history of irritable bowel syndrome presents with acute bowel symptoms, it is important to investigate the underlying cause. However, certain investigations may not be appropriate in this context. For example, an abdominal ultrasound scan is not helpful in investigating bowel symptoms. Similarly, CEA tumour marker testing is a specialist investigation and not suitable for primary care. Ca125 is a marker for ovarian cancer and not relevant in this scenario.

According to NICE guidelines, testing for occult blood in faeces should be offered to assess for colorectal cancer in adults aged 50 and over with unexplained abdominal pain or weight loss, or in those under 60 with changes in their bowel habit or iron-deficiency anaemia. Stool mc+s may be requested, but it would not be helpful in risk stratifying the patient for urgent referral for colorectal cancer if an infective aetiology is not suspected. Therefore, it is important to choose appropriate investigations based on the patient’s symptoms and medical history.

For women who have had gestational diabetes in a previous pregnancy, it is recommended that they undergo an OGTT as soon as possible after their initial booking, and then again at 24-28 weeks. If the first test is normal, they may also be offered early self-monitoring of blood glucose as an alternative. Women who have other risk factors for gestational diabetes, such as a BMI over 30 kg/m², a previous macrosomic baby weighing 4.5 kg or more, a first degree relative with diabetes, or a minority ethnic family origin with a high prevalence of diabetes, but no previous history of gestational diabetes, should be offered an OGTT at 24-28 weeks.

Gestational diabetes is a common medical disorder that affects around 4% of pregnancies. It can develop during pregnancy or be a pre-existing condition. According to NICE, 87.5% of cases are gestational diabetes, 7.5% are type 1 diabetes, and 5% are type 2 diabetes. Risk factors for gestational diabetes include a BMI of > 30 kg/m², previous gestational diabetes, a family history of diabetes, and family origin with a high prevalence of diabetes. Screening for gestational diabetes involves an oral glucose tolerance test (OGTT), which should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal.

To diagnose gestational diabetes, NICE recommends using the following thresholds: fasting glucose is >= 5.6 mmol/L or 2-hour glucose is >= 7.8 mmol/L. Newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week and taught about self-monitoring of blood glucose. Advice about diet and exercise should be given, and if glucose targets are not met within 1-2 weeks of altering diet/exercise, metformin should be started. If glucose targets are still not met, insulin should be added to the treatment plan.

For women with pre-existing diabetes, weight loss is recommended for those with a BMI of > 27 kg/m^2. Oral hypoglycaemic agents, apart from metformin, should be stopped, and insulin should be commenced. Folic acid 5 mg/day should be taken from preconception to 12 weeks gestation, and a detailed anomaly scan at 20 weeks, including four-chamber view of the heart and outflow tracts, should be performed. Tight glycaemic control reduces complication rates, and retinopathy should be treated as it can worsen during pregnancy.

Targets for self-monitoring of pregnant women with diabetes include a fasting glucose level of 5.3 mmol/l and a 1-hour or 2-hour glucose level after meals of 7.8 mmol/l or 6.4 mmol/l, respectively. It is important to manage gestational diabetes and pre-existing diabetes during pregnancy to reduce the risk of complications for both the mother and baby.

Common Male Genital Conditions

Phimosis is a condition where the foreskin cannot be retracted over the glans penis. Physiological phimosis is normal in newborns and usually resolves by 10 years of age. Treatment for pathological phimosis may include topical medication or circumcision if recurrent infections occur. Balanoposthitis is inflammation of the glans and foreskin, often caused by infection or inflammation. Hypospadias is a congenital condition where the urethral opening is on the underside of the penis, and the foreskin may be underdeveloped. Posterior urethral valves are membranes in the posterior urethra that can cause obstruction and frequent infections in boys.

Before initiating an ACE inhibitor in patients with heart failure with a reduced ejection fraction, it is recommended to seek specialist advice if the potassium level is above 5 mmol/L. The current NICE CKS guidance suggests starting bisoprolol and ramipril for such patients. However, if the potassium level is high, it is advisable to repeat the urea and electrolytes in 2-3 weeks and seek specialist advice before starting an ACE inhibitor. As the patient is asymptomatic, increasing the dose of furosemide would not be beneficial. There is no need for same-day medical assessment as the patient is currently stable. Although bendroflumethiazide may be suitable for hypertension, NICE CKS recommends ACEi for heart failure treatment.

Angiotensin-converting enzyme (ACE) inhibitors are commonly used as the first-line treatment for hypertension and heart failure in younger patients. However, they may not be as effective in treating hypertensive Afro-Caribbean patients. ACE inhibitors are also used to treat diabetic nephropathy and prevent ischaemic heart disease. These drugs work by inhibiting the conversion of angiotensin I to angiotensin II and are metabolized in the liver.

While ACE inhibitors are generally well-tolerated, they can cause side effects such as cough, angioedema, hyperkalaemia, and first-dose hypotension. Patients with certain conditions, such as renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema, should use ACE inhibitors with caution or avoid them altogether. Pregnant and breastfeeding women should also avoid these drugs.

Patients taking high-dose diuretics may be at increased risk of hypotension when using ACE inhibitors. Therefore, it is important to monitor urea and electrolyte levels before and after starting treatment, as well as any changes in creatinine and potassium levels. Acceptable changes include a 30% increase in serum creatinine from baseline and an increase in potassium up to 5.5 mmol/l. Patients with undiagnosed bilateral renal artery stenosis may experience significant renal impairment when using ACE inhibitors.

The current NICE guidelines recommend using a flow chart to manage hypertension, with ACE inhibitors as the first-line treatment for patients under 55 years old. However, individual patient factors and comorbidities should be taken into account when deciding on the best treatment plan.

Medical Conditions Associated with Crohn’s Disease

Crohn’s disease is a chronic inflammatory bowel disease that can lead to various medical conditions. One of these conditions is amyloidosis, which occurs when extracellular protein deposits disrupt normal organ function. This can result in nephrotic syndrome, characterized by protein in the urine and edema. While cardiac disease is uncommon in Crohn’s disease, it can occur and may present as congestive heart failure. Cirrhosis of the liver is also a potential complication, particularly in cases of primary sclerosing cholangitis. However, there is no indication of liver failure in the presented case. Nephritic syndrome, which involves protein and blood in the urine, is not the likely cause of the patient’s symptoms. While cutaneous manifestations such as blisters can occur in Crohn’s disease, pemphigus is a rare association and is not the likely cause of the patient’s edema and proteinuria.

Notifying the coroner is not legally required for this death, but it must be reported to the Local Authority Proper Officer under the Health Protection Regulations 2010.

Notifiable Deaths and Reporting to the Coroner

When it comes to death certification, certain deaths are considered notifiable and should be reported to the coroner. These include unexpected or sudden deaths, as well as deaths where the attending doctor did not see the deceased within 28 days prior to their passing (this was increased from 14 days during the COVID pandemic). Additionally, deaths that occur within 24 hours of hospital admission, accidents and injuries, suicide, industrial injury or disease, deaths resulting from ill treatment, starvation, or neglect, deaths occurring during an operation or before recovery from the effect of an anaesthetic, poisoning (including from illicit drugs), stillbirths where there is doubt as to whether the child was born alive, and deaths of prisoners or people in police custody are also considered notifiable.

It is important to note that these deaths should be reported to the coroner, who will then investigate the circumstances surrounding the death. This is to ensure that any potential criminal activity or negligence is properly addressed and that the cause of death is accurately determined. By reporting notifiable deaths to the coroner, we can help ensure that justice is served and that families receive the closure they need during a difficult time.

Understanding Premenstrual Syndrome (PMS)

Premenstrual syndrome (PMS) is a condition that affects women during the luteal phase of their menstrual cycle. It is characterized by emotional and physical symptoms that can range from mild to severe. PMS only occurs in women who have ovulatory menstrual cycles and doesn’t occur before puberty, during pregnancy, or after menopause.

Emotional symptoms of PMS include anxiety, stress, fatigue, and mood swings. Physical symptoms may include bloating and breast pain. The severity of symptoms varies from woman to woman, and management options depend on the severity of symptoms.

Mild symptoms can be managed with lifestyle advice, such as getting enough sleep, exercising regularly, and avoiding smoking and alcohol. Specific advice includes eating regular, frequent, small, balanced meals that are rich in complex carbohydrates.

Moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP), such as Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg). Severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI), which can be taken continuously or just during the luteal phase of the menstrual cycle (for example, days 15-28, depending on the length of the cycle). Understanding PMS and its management options can help women better cope with this condition.

GLP-1 mimetics have been linked with an increased risk of severe pancreatitis, according to an alert issued by the MHRA in 2014. It is important to suspend GLP-1 mimetics immediately if pancreatitis is suspected. However, they do not cause appendicitis, drug-induced hepatitis, or acute mesenteric ischaemia.

Diabetes mellitus is a condition that has seen the development of several drugs in recent years. One hormone that has been the focus of much research is glucagon-like peptide-1 (GLP-1), which is released by the small intestine in response to an oral glucose load. In type 2 diabetes mellitus (T2DM), insulin resistance and insufficient B-cell compensation occur, and the incretin effect, which is largely mediated by GLP-1, is decreased. GLP-1 mimetics, such as exenatide and liraglutide, increase insulin secretion and inhibit glucagon secretion, resulting in weight loss, unlike other medications. They are sometimes used in combination with insulin in T2DM to minimize weight gain. Dipeptidyl peptidase-4 (DPP-4) inhibitors, such as vildagliptin and sitagliptin, increase levels of incretins by decreasing their peripheral breakdown, are taken orally, and do not cause weight gain. Nausea and vomiting are the major adverse effects of GLP-1 mimetics, and the Medicines and Healthcare products Regulatory Agency has issued specific warnings on the use of exenatide, reporting that it has been linked to severe pancreatitis in some patients. NICE guidelines suggest that a DPP-4 inhibitor might be preferable to a thiazolidinedione if further weight gain would cause significant problems, a thiazolidinedione is contraindicated, or the person has had a poor response to a thiazolidinedione.

To intensify the drug treatment for this patient, a second agent should be added if her HbA1c level reaches 58 mmol/mol. It is recommended to advise adults with type 2 diabetes to maintain their HbA1c level below their target if they are not experiencing hypoglycaemia.

NICE has updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022 to reflect advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. For the average patient taking metformin for T2DM, lifestyle changes and titrating up metformin to aim for a HbA1c of 48 mmol/mol (6.5%) is recommended. A second drug should only be added if the HbA1c rises to 58 mmol/mol (7.5%). Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates, controlling intake of saturated fats and trans fatty acids, and initial target weight loss of 5-10% in overweight individuals.

Individual HbA1c targets should be agreed upon with patients to encourage motivation, and HbA1c should be checked every 3-6 months until stable, then 6 monthly. Targets should be relaxed on a case-by-case basis, with particular consideration for older or frail adults with type 2 diabetes. Metformin remains the first-line drug of choice, and SGLT-2 inhibitors should be given in addition to metformin if the patient has a high risk of developing cardiovascular disease (CVD), established CVD, or chronic heart failure. If metformin is contraindicated, SGLT-2 monotherapy or a DPP-4 inhibitor, pioglitazone, or sulfonylurea may be used.

Further drug therapy options depend on individual clinical circumstances and patient preference. Dual therapy options include adding a DPP-4 inhibitor, pioglitazone, sulfonylurea, or SGLT-2 inhibitor (if NICE criteria are met). If a patient doesn’t achieve control on dual therapy, triple therapy options include adding a sulfonylurea or GLP-1 mimetic. GLP-1 mimetics should only be added to insulin under specialist care. Blood pressure targets are the same as for patients without type 2 diabetes, and ACE inhibitors or ARBs are first-line for hypertension. Antiplatelets should not be offered unless a patient has existing cardiovascular disease, and only patients with a 10-year cardiovascular risk > 10% should be offered a statin.

Changes in General Practice Consultation Trends: A Retrospective Cohort Study

A retrospective cohort study has revealed significant changes in General Practice (GP) consultation trends, particularly in the type of consultations offered. The COVID-19 pandemic has led to a shift away from face-to-face consultations towards other means of consulting. Frequent attenders are now consulting proportionally more over time, accounting for almost half of all GP consultations and five times more than the rest of the Practice population. This trend is evident across all consultation modalities, including face-to-face. However, the proportion of consultations with frequent attenders has dropped since 2000, despite GP consultations with frequent attenders increasing from a median of 13% to 21% over the same period. Currently, one in ten GP consultations (of any type) are with frequent attenders, and these have proportionally increased in the last 20 years. Although there has been a reduction in face-to-face consultations and a significant increase in online/telephone consultations, overall appointments have continued to increase. Face-to-face consultations have reduced in number, both for GPs and other clinical staff.

Infertility Management and Referral Criteria

Infertility is a common issue that affects many couples. According to the Clinical Knowledge Summaries, if a couple has been having regular unprotected sexual intercourse for one year and are without comorbidities that affect fertility, investigation into the cause of infertility should be initiated. If no cause is found, the couple should be referred for specialist input.

The referral criteria for infertility may vary between health authorities, so it is important to refer to local guidelines. However, in general, if the woman is younger than 36 years and history, examination, and investigations are normal in both partners, referral should be considered if the couple has not conceived after one year. If the woman is aged 36 years or older, referral should be considered after six months. Earlier referral may be necessary if there is a known cause for infertility, a history of factors that predispose to infertility, or if treatment is planned that may result in infertility.

It is important to ensure that the couple has been offered counselling before, during, and after investigation and treatment, regardless of the outcome. Infertility and its investigation and treatment can cause psychological stress, and infertility counsellors are provided by all licensed clinics in the UK through the British Infertility Counselling Association.

Febrile convulsions are seizures that occur in otherwise healthy children when they have a fever. They are most common in children between the ages of 6 months and 5 years, affecting around 3% of children. Febrile convulsions usually occur at the onset of a viral infection when the child’s temperature rises rapidly. The seizures are typically brief, lasting less than 5 minutes, and are usually tonic-clonic in nature.

There are three types of febrile convulsions: simple, complex, and febrile status epilepticus. Simple febrile convulsions last less than 15 minutes and are generalised seizures. Complex febrile convulsions last between 15 and 30 minutes and may be focal seizures. Febrile status epilepticus lasts for more than 30 minutes. Children who have had their first seizure or any features of a complex seizure should be admitted to paediatrics.

Following a seizure, parents should be advised to call an ambulance if the seizure lasts longer than 5 minutes. Regular antipyretics have not been shown to reduce the chance of a febrile seizure occurring. If recurrent febrile convulsions occur, benzodiazepine rescue medication may be considered, but this should only be started on the advice of a specialist, such as a paediatrician. Rectal diazepam or buccal midazolam may be used.

The overall risk of further febrile convulsions is 1 in 3, but this varies depending on risk factors for further seizure. These risk factors include age of onset under 18 months, fever below 39ºC, shorter duration of fever before the seizure, and a family history of febrile convulsions. Children with no risk factors have a 2.5% risk of developing epilepsy, while those with all three risk factors have a much higher risk of developing epilepsy, up to 50%.

Based on the patient’s travel history to Afghanistan and the presence of a painless single lesion, the most probable diagnosis is cutaneous leishmaniasis. Although primary syphilis can also present with a painless lesion, the size and location of the lesion on the back of the hand is atypical. Pyoderma gangrenosum typically causes pain and presents more acutely. While a buruli ulcer can also present similarly, it is rare, mostly found in children, and has not been reported in the Middle East.

Source: WHO fact sheets on leishmaniasis
Cutaneous leishmaniasis is transmitted by sandflies and usually manifests as an erythematous patch or papule that gradually enlarges and becomes an ulcer with a raised indurated border. In dry forms, the lesion is crusted with a raised edge. It is usually painless unless a secondary bacterial infection is present. Afghanistan has particularly high levels of cutaneous leishmaniasis.

Leishmaniasis: A Disease Caused by Sandfly Bites

Leishmaniasis is a disease caused by the protozoa Leishmania, which are transmitted through the bites of sandflies. There are three main forms of the disease: cutaneous, mucocutaneous, and visceral. Cutaneous leishmaniasis is characterized by a crusted lesion at the site of the bite, which may be accompanied by an underlying ulcer. It is typically diagnosed through a punch biopsy from the edge of the lesion. Mucocutaneous leishmaniasis can spread to involve the mucosae of the nose, pharynx, and other areas. Visceral leishmaniasis, also known as kala-azar, is the most severe form of the disease and is characterized by fever, sweats, rigors, massive splenomegaly and hepatomegaly, poor appetite, weight loss, and grey skin. The gold standard for diagnosis is bone marrow or splenic aspirate. Treatment is necessary for cutaneous leishmaniasis acquired in South or Central America due to the risk of mucocutaneous leishmaniasis, while disease acquired in Africa or India can be managed more conservatively.

A potential indication of referred lumbar spine pain causing hip pain is a positive result on the femoral nerve stretch test. This is because compression of the femoral nerve may be the root cause of the pain, and stretching the nerve can reproduce the symptoms.

Hip pain in adults can be caused by a variety of conditions. Osteoarthritis is a common cause, with pain that worsens with exercise and improves with rest. Reduced internal rotation is often the first sign, and risk factors include age, obesity, and previous joint problems. Inflammatory arthritis can cause pain in the morning, systemic symptoms, and elevated inflammatory markers. Referred lumbar spine pain may be caused by femoral nerve compression, which can be tested with a positive femoral nerve stretch test. Greater trochanteric pain syndrome, or trochanteric bursitis, is often seen in women aged 50-70 and is caused by repeated movement of the iliotibial band. Meralgia paraesthetica is caused by compression of the lateral cutaneous nerve of the thigh and results in a burning sensation over the antero-lateral aspect of the thigh. Avascular necrosis can have gradual or sudden onset and may follow high dose steroid therapy or previous hip fracture or dislocation. Pubic symphysis dysfunction is common in pregnancy and causes pain over the pubic symphysis with radiation to the groins and medial aspects of the thighs. Transient idiopathic osteoporosis is an uncommon condition sometimes seen in the third trimester of pregnancy, causing groin pain and limited range of movement in the hip, with elevated ESR.

Legionella is often characterized by symptoms resembling the flu, such as a dry cough, confusion, and a slower than normal heart rate. Additionally, hyponatraemia may be detected through blood tests. If the individual has recently traveled abroad, this may also indicate a potential Legionella infection.

Legionnaires Disease: Symptoms, Diagnosis, and Management

Legionnaires disease is a type of pneumonia caused by the Legionella pneumophilia bacterium. It is commonly found in water tanks and air-conditioning systems, and is often associated with foreign travel. Unlike other types of pneumonia, Legionnaires disease cannot be transmitted from person to person. Symptoms of the disease include flu-like symptoms such as fever, dry cough, confusion, and lymphopaenia. In addition, patients may experience hyponatraemia, deranged liver function tests, and pleural effusion in around 30% of cases.

Diagnosis of Legionnaires disease is typically done through a urinary antigen test. Treatment involves the use of antibiotics such as erythromycin or clarithromycin. Chest x-rays may show nonspecific features, but often include patchy consolidation in the mid-to-lower zones and pleural effusions. It is important to be aware of the symptoms and risk factors associated with Legionnaires disease in order to ensure prompt diagnosis and treatment.

Borderline Personality Disorder: Understanding the Challenges

Borderline Personality Disorder (BPD) is a complex mental health condition that can present significant challenges in managing both the mental and physical needs of those affected. BPD is the most commonly presenting personality disorder in primary care, and it is important to recognise the signs and symptoms to provide appropriate support.

Individuals with BPD often exhibit a pervasive pattern of behaviour characterised by unstable interpersonal relationships, problems with self-image and mood, and impulsive behaviour. They may experience suicidal tendencies, self-harm, depression, and even psychotic symptoms. Patients can fluctuate rapidly between periods of confidence and complete despair, and they often show fear of abandonment and rejection.

Recognising the signs and symptoms of BPD is crucial in providing appropriate support and treatment for those affected. With the right care and management, individuals with BPD can lead fulfilling lives and achieve their full potential.

Based on the patient’s symptoms and history, the most likely diagnosis is Hepatitis A. The initial fever, anorexia, and malaise followed by jaundice and elevated liver enzymes are typical of Hep A. A confirmation test for anti-Hep A immunoglobulin M can be done. Hep A is not common in the UK but is more prevalent in areas with poor sanitation, especially among travelers. Cytomegalovirus infection can also cause a mononucleosis-like syndrome with fever, splenomegaly, and mild liver enzyme increases, but rises in ALP and bilirubin are less common. Hep B and C are unlikely as there are no risk factors in the patient’s history. Leptospirosis, which is associated with exposure to rat-infected water and conjunctival suffusion, is less likely than Hep A.

Managing Diabetes Mellitus During Ramadan

Type 2 diabetes mellitus is more prevalent in people of Asian ethnicity, including a significant number of Muslim patients in the UK. With Ramadan falling in the long days of summer, it is crucial to provide appropriate advice to Muslim patients to ensure they can safely observe their fast. While it is a personal decision whether to fast, it is worth noting that people with chronic conditions are exempt from fasting or may delay it to shorter days in winter. However, many Muslim patients with diabetes do not consider themselves exempt from fasting. Around 79% of Muslim patients with type 2 diabetes mellitus fast during Ramadan.

To help patients with type 2 diabetes mellitus fast safely, they should consume a meal containing long-acting carbohydrates before sunrise (Suhoor). Patients should also be given a blood glucose monitor to check their glucose levels, especially if they feel unwell. For patients taking metformin, the dose should be split one-third before sunrise (Suhoor) and two-thirds after sunset (Iftar). For those taking sulfonylureas, the expert consensus is to switch to once-daily preparations after sunset. For patients taking twice-daily preparations such as gliclazide, a larger proportion of the dose should be taken after sunset. No adjustment is necessary for patients taking pioglitazone. Diabetes UK and the Muslim Council of Britain have an excellent patient information leaflet that explores these options in more detail.

Managing diabetes mellitus during Ramadan is crucial to ensure Muslim patients with type 2 diabetes mellitus can safely observe their fast. It is important to provide appropriate advice to patients, including consuming a meal containing long-acting carbohydrates before sunrise, checking glucose levels regularly, and adjusting medication doses accordingly.

Management of Otitis Media with Effusion (Glue Ear)

Eighty percent of children under 10-years-old will have experienced at least one episode of otitis media with effusion (OME), commonly known as glue ear. This condition is characterized by relapsing and remitting episodes that can last for 6-10 weeks, with bimodal peaks at 2 and 5 years of age. The main concern with glue ear is the associated conductive hearing impairment, which can have significant repercussions for a child’s education and speech and language development.

In cases where symptoms persist, specialist referral to audiometry or ENT for hearing assessment is indicated, probably leading to the need for ENT intervention (grommet insertion) based on the clinical picture (developmental issues are present and the problems are persistent). It is worth noting that antibiotics, topical and systemic steroids, decongestants, mucolytics, and antihistamines are not recommended in the routine management of OME.

The National Institute for Health and Care Excellence (NICE) guidelines recommend a period of watchful waiting for three months, with two pure-tone audiograms three months apart, to confirm and quantify the hearing loss. Audiometry is important to ensure there is not a more significant hearing deficit. Ultimately, surgical treatment in the form of ventilation tube (grommet) insertion is effective in managing OME.

Lethargy is a common early symptom of multiple sclerosis, an autoimmune condition that affects the myelin in the brain and spinal cord. The patient’s description of symptoms of optic neuritis is also typical of multiple sclerosis. Lyme disease can sometimes mimic multiple sclerosis, but there is no history of a tick bite. Myasthenia gravis, which causes weakness and fatigue, is not likely to cause paresthesia or optic neuritis. Sarcoidosis, a systemic inflammatory disease that often presents with fatigue, is a potential option, but multiple sclerosis is more likely to cause optic neuritis.

Features of Multiple Sclerosis

Multiple sclerosis (MS) is a condition that can present with nonspecific features, such as significant lethargy in around 75% of patients. Diagnosis is based on two or more relapses and either objective clinical evidence of two or more lesions or objective clinical evidence of one lesion with reasonable historical evidence of a previous relapse.

MS can affect various parts of the body, leading to different symptoms. Visual symptoms include optic neuritis, optic atrophy, Uhthoff’s phenomenon, and internuclear ophthalmoplegia. Sensory symptoms may include pins and needles, numbness, trigeminal neuralgia, and Lhermitte’s syndrome. Motor symptoms may include spastic weakness, which is most commonly seen in the legs. Cerebellar symptoms may include ataxia and tremor. Other symptoms may include urinary incontinence, sexual dysfunction, and intellectual deterioration.

It is important to note that MS symptoms can vary greatly between individuals and may change over time. Therefore, it is crucial for patients to work closely with their healthcare providers to manage their symptoms and receive appropriate treatment.

Early Detection of Cancer in Primary Care

Early detection of cancer in primary care is crucial for improving survival and outcomes. Clinicians rely on identifying ‘red flag’ symptoms that should prompt urgent referral for specialist investigation. NICE guidelines have been published to help clinicians identify these symptoms and clarify who should be referred with speed. For instance, people aged 45 and over with unexplained visible haematuria without urinary tract infection should be referred using a suspected cancer pathway referral.

In some cases, urgent referral is not necessary, but careful monitoring and follow-up are required. For example, a 50-year-old woman with bilateral eczematous skin on her left breast should be treated with topical treatment for the eczematous patch and referred if the eczema doesn’t respond to treatment. However, unilateral eczema around the nipple could represent Paget’s disease and would warrant urgent referral.

Similarly, any postmenopausal woman who presents with vaginal bleeding should be referred urgently immediately. If a woman on hormone replacement therapy presents with postmenopausal bleeding, the HRT should be stopped, and an urgent referral made if any persistent or unexplained bleeding doesn’t resolve over a six-week period.

In some cases, further investigation is required before referral. For instance, a 70-year-old man with a persistent cough for the last four weeks that is not improving should be referred for an urgent chest x-ray. Further management/investigation would depend on the results of the x-ray and the pattern of any ongoing symptoms. Immediate urgent referral for suspected cancer is not indicated at this point.

Finally, it is essential to consider other factors that could explain the symptoms. For example, a 39-year-old’s low Hb could be explained by her menorrhagia. Overall, early detection of cancer in primary care requires careful consideration of symptoms, risk factors, and appropriate referral pathways.

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

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

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

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

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

Ocular Manifestations of Infectious Diseases

Choroidal tubercles, toxocariasis, Kaposi’s sarcoma, syphilis, and toxoplasmosis are all infectious diseases that can manifest in the eye. Choroidal tubercles are a common presentation of intraocular tuberculosis, while toxocariasis is caused by roundworm larvae migration and can lead to ocular larva migrans. Kaposi’s sarcoma presents as highly vascular lesions on the eyelids, conjunctiva, caruncle, and lacrimal sac. Syphilis can cause optic neuritis, uveitis, and interstitial keratitis, while toxoplasmosis can lead to chorioretinitis and vitreous inflammation. It is important to consider these infectious diseases in patients presenting with ocular symptoms and to evaluate for systemic involvement.

Men who engage in sexual activity with other men should be offered immunization against hepatitis A, according to the Green Book guidelines. It is recommended that MSM with multiple sexual partners be informed about the risks of hepatitis A and the importance of maintaining good personal hygiene. Immunization should be offered to these individuals, especially during periods of outbreaks. Additionally, MSM should also be offered vaccination for hepatitis B and HPV. Unfortunately, there is currently no vaccine available for hepatitis C, hepatitis D, gonorrhea, or genital herpes. However, these STIs can be treated with medication.

Understanding Hepatitis A: Symptoms, Transmission, and Prevention

Hepatitis A is a viral infection that affects the liver. It is usually a mild illness that resolves on its own, with serious complications being rare. The virus is transmitted through the faecal-oral route, often in institutions. The incubation period is typically 2-4 weeks, and symptoms include a flu-like prodrome, abdominal pain (usually in the right upper quadrant), tender hepatomegaly, jaundice, and deranged liver function tests.

While complications are rare, there is no increased risk of hepatocellular cancer. An effective vaccine is available, and it is recommended for people travelling to or residing in areas of high or intermediate prevalence, those with chronic liver disease, patients with haemophilia, men who have sex with men, injecting drug users, and individuals at occupational risk (such as laboratory workers, staff of large residential institutions, sewage workers, and people who work with primates).

It is important to note that the vaccine requires a booster dose 6-12 months after the initial dose. By understanding the symptoms, transmission, and prevention of hepatitis A, individuals can take steps to protect themselves and others from this viral infection.

Intermittent Self-Catheterisation: A Safe and Effective Way to Manage Urinary Retention and Incontinence

Intermittent self-catheterisation is a safe and effective method for managing urinary retention or incontinence caused by a neuropathic or hypotonic bladder. This technique provides patients with freedom from urinary collection systems. Although it may not be feasible for some patients, severe disability is not a contra-indication. Patients in wheelchairs have successfully mastered the technique despite various physical and mental challenges.

Single-use catheters are sterile and come with either a hydrophilic or gel coating. The former requires immersion in water for 30 seconds to activate, while the latter doesn’t require any preparation before use. Reusable catheters are made of polyvinyl chloride and can be washed and reused for up to a week.

While other types of catheterisation are available, intermittent self-catheterisation is typically the first choice. Oxybutynin, an anticholinergic medication, is used to relieve urinary difficulties, including frequent urination and urge incontinence, by decreasing muscle spasms of the bladder. However, in patients with overflow incontinence due to diabetes or neurological diseases like multiple sclerosis or spinal cord trauma, oxybutynin can worsen overflow incontinence because the fundamental problem is the bladder not contracting. The same is true for imipramine.

NICE Guidance on Antidepressant Use for Recurrent Depression

According to NICE guidance, patients who have experienced two or more depressive episodes in the recent past and have suffered significant functional impairment during these episodes should be advised to continue taking antidepressants for a period of two years. This recommendation is based on evidence that suggests that longer-term use of antidepressants can reduce the risk of relapse and recurrence of depression. It is important to note that this guidance applies specifically to patients with recurrent depression and should be considered on a case-by-case basis in consultation with a healthcare professional.

Understanding Nephrotic Syndrome: Causes and Mechanisms

Nephrotic syndrome is a condition characterized by proteinuria, hypoalbuminemia, edema, and hyperlipidemia. The primary causes of nephrotic syndrome include minimal-change nephropathy, focal glomerulosclerosis, and membranous nephropathy, while secondary causes include systemic diseases and drugs. Membranous glomerulonephritis is the most common cause of nephrotic syndrome in adults.

The glomerular structural changes that may cause proteinuria involve damage to the endothelial surface, the glomerular basement membrane, or the podocytes. In membranous glomerulonephritis, immune complexes localize between the outer aspects of the basement membrane and the podocytes.

If left untreated, nephrotic syndrome can progress to end-stage renal failure in 30-50% of patients. However, some patients with idiopathic membranous nephropathy may experience complete or partial spontaneous remission of nephrotic syndrome with stable renal function.

It is important to differentiate nephrotic syndrome from other kidney conditions such as diffuse proliferative glomerulonephritis, IgA nephropathy, acute tubular necrosis, and acute interstitial nephritis. Understanding the causes and mechanisms of nephrotic syndrome can aid in proper diagnosis and treatment.

Carotid Endarterectomy and Stenting for Severe Carotid Stenosis

Carotid endarterectomy is a surgical procedure recommended by NICE for patients with moderate or severe carotid stenosis. It is most beneficial for those with severe stenosis, reducing the risk of stroke by up to 30% over three years. However, the presence of a carotid bruit alone is not enough to confirm or exclude significant stenosis or its severity.

Carotid endarterectomy is indicated for patients with recent stroke or transient ischaemic attack, but surgery should be carried out within seven days of symptom onset for maximum benefit. While stenting with an emboli protection device may be as effective as endarterectomy, there may be a higher risk of stroke initially post-procedure.

In addition to surgical intervention, the best medical management includes lowering blood pressure, treatment with statins, and antiplatelet therapy. It is important to start treatment as soon as possible to maximize the benefits of surgery.